Application for Associate Membership

Application for
Associate Membership
August
to
December
for applicants not
requiring insurance or
requiring only student
insurance to be used in
supervised practice
2014
Vision
Wellness through natural health.
Mission
We champion professional excellence to support
the growth of natural health and wellness.
Values
We believe in and support choice, competency, efficacy, inclusivity,
integrity, and responsiveness.
6TH FLOOR, 10339
email: memberservices@nhpcanada.org
1toll-free:
2 4 S 1-888-711-7701
T, EDMONTON, AB T5N 3W1
fax: 780-484-3605
Application for Associate Membership
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
Required Documents (submit with this application)
if you are a student, a letter confirming enrollment in an NHPC recognized program
a Criminal Record Check with the Vulnerable Sector Search completed within the last 30 days
If your letter of enrollment or criminal record check are not attainable at the time you submit this application, you must
submit them within 30 days of the date in which this application for membership is received at the NHPC. If the above-listed
documents are not received within that 30 days, your membership will be revoked. If your criminal record check is not
submitted with this form, you must submit a payment receipt or copy of the criminal record check application.
if you are currently registered with a provincially legislated massage therapy regulatory body (CMTBC, CMTO, or NLMTB),
provide a copy of your registration
if the name on this application is different than the name on the documents submitted with it, provide proof of name change
Language Preference:
English
French
Male
Female
Personal Information (required)
First Name
Initial
Last Name
Address
City
Home Phone
Province
Postal Code
Cell Phone
Email (used for your website member account login and confidential communications)
Previous NHPC/AMTWP Member Number(s) (if applicable)
Fax
Birthdate (MM/DD/YYYY)
Are you currently a student in an NHPC recognized program?
Yes
No
Gender:
If "Yes", anticipated graduation date (MM/DD/YYYY)
Referral Information (required if applicable)
Did NHPC give a presentation at your school?
Yes
No
If "yes", when? (MM/YYYY)
Name of your school
Preferences (required)
Send me information on NHPC benefit partner programs (discounted products and services):
Yes
No
Send me the yearly catalogue for the NHPC Centre for Learning (NHPC learning opportunities) by:
Email
Mail
Send me the yearly brochure for the NHPC Annual National Conference by:
Email
Mail
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: growingtogether@nhpcanada.org
Page 1
of 7
Application for Associate Membership
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
Current Practice (required)
Have you been practicing as a professional in your field as a massage therapist or a holistic practitioner?
If "Yes", complete the rest of this section (Current Practice). If "No", proceed to the next section (Legal).
Yes
No
Do you complete a preliminary assessment to identify contraindications to services?
Yes
No
Do you obtain a signed waiver from clients acknowledging disclosure of limits, contraindications, and
possible side effects of services to be provided?
Yes
No
Do you adhere to informed consent within your regular practice at all times?
Yes
No
Do you sell products as part of your practice (oils, lotions, aromatherapy products)?
If so, please list:
Yes
No
Have you ever pled guilty to or been convicted of a criminal offense for which you have not been
pardoned? (See the Required Documents section at the top of this application form.)
Yes
No
Have you ever been subject to a professional conduct disciplinary process or been disciplined by a
professional body?
Yes
No
In what type of setting do/will you practice, if known? (check all that apply)
Private practice in clinic or office
Private Practice in home
On-site (company or client's home)
Fitness centre, spa, or health club
Resort or hotel
Other:______________________________________
Sports medicine facility
Chiropractic or physiotherapy office
Group practice-rehabilitation
Holistic health centre
Hospital, nursing home, or hospice
Legal (required)
NHPC Privacy Statement
The NHPC is a national association committed to privacy best practices across the provinces and territories of Canada. The
NHPC collects, uses, and discloses personal information in accordance with the NHPC Privacy Policy. A copy of this policy can
be found on the NHPC website (www.nhpcanada.org). By signing this application, I confirm that I have read the NHPC
Privacy Policy and I consent to the collection, use, and disclosure of my personal information in accordance with the
NHPC Privacy Policy.
Agreement
I, the undersigned, declare that to the best of my knowledge, the information provided and statements made in this application
(pages 1–7 inclusive) and in any attached documents are true. I agree to abide by the Bylaws of the NHPC, as amended or
replaced from time to time, and have read and agree to comply with the NHPC Code of Ethics. I realize that I may lose my
membership and membership privileges if complaints about my practice are found to be in violation of the Code of Ethics, or not
in the best interest of the public.
Signature
Date (MM/DD/YYYY)
If you are a student requiring insurance for a supervised practicum setting, complete the following insurance
application (pages 3–5). Otherwise, proceed directly to Payment for Associate Membership (pages 6–7).
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: growingtogether@nhpcanada.org
Page 2
of 7
Student Liability Insurance Application
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
Applicant Contact Information (required)
First Name
Initial
Home Address
City
Home Phone
Last Name
Province
Cell Phone
Email
Postal Code
Fax
Website
Regulation of Practice (required)
See the Required Documents section at the top of the Regular Membership application.
Have you ever been disciplined or expelled from an association or legislated regulatory body?
If "Yes", Name of Association/Regulatory Body
Yes
No
Yes
No
Yes
No
Date of Expulsion (MM/DD/YYYY)
Reason for Expulsion or Disciplinary Action
Prior Insurance (required)
Have you ever incurred any prior liability claims or losses?
If "Yes", briefly summarize the claim or loss
In the past three years, have you had liability insurance cancelled or coverage refused by an insurer?
If "Yes", Explain
With what Insurance Company were you previously insured for liability insurance? (Indicate “N/A” if no previous insurance)
Professional Liability Insurance/Medical Malpractice
Commercial General Liability (CGL)
Insurance Company Name (not the broker)
Insurance Company Name (not the broker)
Policy No.
Policy No.
Expiry Date (MM/DD/YYYY)
Expiry Date (MM/DD/YYYY)
Was this a claims based policy?
Yes
No
Operations (required)
In the normal course of your practice do you do any of the following? (check all that apply)
Insert fluids, chemicals or foreign objects into bodily orifices
Puncture or other otherwise traumatize the dermis
Perform ear candling
Treat and/or have care, custody and control of animals
Use any sun tanning or related equipment, X-rays, infrared ray, diathermy, quartz lamp, teletherapy units, radium or
radioisotopes
Provide any advice relating to the ingestion of products such as herbal products, nutritional supplements, plant medicine or
chemical substances?
Provide lifestyle/attitudinal or general nutritional counseling beyond that associated with a defined discipline, specialty or
technique or training program approved for membership status by the NHPC
Describe yourself as a "naturopath"
The NHPC Medical Malpractice insurance component under the Liability Insurance program policy excludes the above
practices (those indicated in the Operations section), except as follows:
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: growingtogether@nhpcanada.org
Page 3
of 7
Student Liability Insurance Application
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
Insertion of fluids, chemicals or foreign objects into bodily orifices, including colonic irrigations, naturopathy, advice relating to the
ingestion of herbs, nutritional supplements, plant medicine or chemical substances, with the exception of bona fide members of
the NHPC who were practicing and qualified to perform the above modalities and practices on or prior to July 31, 2001, with
credentials acceptable to the NHPC, and who were members insured under policy # MMC9-0001, issued by Scottish & York
Insurance Co., Ltd., under the NHPC Professional Liability Insurance Program in force as of July 31, 2001.
The NHPC carries out detailed credentialing of all practising members. In no event are such modalities and practices covered
under the Medical Malpractice insurance policy if any such modalities and practices falls outside the defined disciplines,
techniques or specialties approved for membership with the NHPC. If you provide any of these excluded services, please
contact the NHPC to discuss these.
Liability Insurance Program Limits
Mandatory
Medical Malpractice Liability – $3,000,000 each Claim (Occurrence based), $5,000,000 Annual Aggregate;
Legal Expense - $25,000 each Claim, $50,000 Annual Aggregate (applicable to members subject to professional disciplinary
legislation: ON, BC and NL only).
Pays for claims against the member alleging negligence in the treatment of a patient as a result of the member’s bodywork,
resulting in bodily injury, sickness or disease.
Optional
Commercial General Liability (CGL) – $3,000,000 each Occurrence, $5,000,000 Annual Aggregate.
Pays for claims against the member alleging negligence in the operation of the business, causing bodily injury or property
damage, including slips and falls, damage to rented or adjacent premises, and injury from products sold.
Note: This policy excludes claims arising out of any service, treatment, advice or instruction for the purpose of appearance or
skin enhancement, hair removal or replacement or personal grooming.
Premium Calculations
Student member premiums are based on a flat annual charge and coverage expiry coincides with your membership renewal
date. Your insurance premium is included in your membership fee. Student members who complete their training during the
policy term do not need to change their insurance, but should contact the NHPC to obtain full membership status.
There is one Master Policy which renews every year on November 1, upon which terms and conditions and pricing for the
program may change.
Insurance Selection (required)
Are you a student practitioner treating patients/other students only under the supervision of a qualified
practitioner/employee of an NHPC approved educational institution?
Yes
No
Are you a student practitioner entitled to treat patients as part of your curriculum outside an academic
setting and without supervision by a practitioner/employee of an NHPC approved educational institution?
Yes
No
If you answered "Yes" to question 2, you should select Option 1, Medical Malpractice & Commercial General Liability.
By selecting Option 2, Medical Malpractice ONLY, in the event of a claim for other than Medical Malpractice related claims,
you will have no coverage for claims such as those of the type listed under the Commercial General Liability description above.
I have read the above and I am selecting:
Option 1: the Medical Malpractice and CGL Package
Preferred Insurance Coverage Start Date (MM/DD/YYYY)
Option 2: the Medical Malpractice ONLY Package
Note: Your insurance coverage start date cannot be prior to this application and
all required documents being received by the NHPC office.
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: growingtogether@nhpcanada.org
Page 4
of 7
Student Liability Insurance Application
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
Premium and Tax Breakdown (required)
Select your insurance premium and associated taxes (if applicable for your province of residence) from the table below, based on
your insurance selection (Option 1 or Option 2) and your preferred insurance coverage start date indicated above.
Start
Month
Aug-2014
Option 1 – Medical Malpractice & CGL
Premium
MB Tax
QC Tax
ON Tax
82.00
6.56
7.38
6.56
Option 2 – Medical Malpractice ONLY
Premium
MB Tax
QC Tax
ON Tax
52.00
4.16
4.68
4.16
Expiry
Date
1-May-2015
Sept-2014
74.00
5.92
6.66
5.92
47.00
3.76
4.23
3.76
1-May-2015
Oct-2014
119.00
9.52
10.71
9.52
76.00
6.08
6.84
6.08
1-Nov-2015
Nov-2014
110.00
8.80
9.90
8.80
70.00
5.60
6.30
5.60
1-Nov-2015
Dec-2014
101.00
8.08
9.09
8.08
64.00
5.12
5.76
5.12
1-Nov-2015
Premium Plus Tax (if applicable) Total Amount
$
Note: This is to verify the amount out of your total membership fee that you are paying
for insurance. It is included in the amount you will select on the payment pages.
In accordance with NHPC membership terms and conditions, insurance premiums under this program are considered to be fully
earned and subject to a no refund policy, regardless if insurance is cancelled by member request.
Legal (required)
The undersigned confirms and warrants that the information provided herein and hereafter is complete and accurate. Application
is subject to review and acceptance by the NHPC and the insurer, and the information contained within this application forms part
of the insurance contract. All sections must be completed, and the application signed and dated in order to be accepted. The
undersigned must be a member in good standing of the NHPC to be eligible for this insurance coverage. This application is not a
Binder of Insurance. The effective date of insurance shall be the date upon which the completed and signed application and
payment are received at the NHPC office, subject to the insurer’s acceptance of the application, and shall be indicated on the
Certificate of Insurance provided to the undersigned. Coverage is subject to the terms and conditions of the Master Policy
wordings.
Privacy Notice
Subject to the law and Aon’s privacy policy (available online at “www.aon.ca”), I consent to the collection, use and disclosure of
any personal information required for the purposes of assessing my application, providing me with requested insurance products,
services or information, assessing my ongoing needs and offering products or services to meet those needs, communicating with
me, claims administration, data analysis and to detect and prevent fraud.
Signature
Program Sponsor:
Date (MM/DD/YYYY)
Program Insurer:
Program Administrator:
For NHPC Office Use Only (do not complete)
Checked By
Date (MM/DD/YYYY)
Member Number Assigned
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: growingtogether@nhpcanada.org
Page 5
of 7
Payment for Associate Membership
Including Student Liability Insurance
Payment for Associate Membership
Select the appropriate fee for your province, membership type, and insurance choice. Where applicable, fee includes insurance
premium, insurance program management fee, membership application fee, membership dues, and provincial taxes.
Associate Non-Student Membership
Join
NHPC
Aug-2014
Resident of
Resident of
Resident of
Resident of
AB, BC, MB, NT, NU, QC SK, YT
ON, NB, NL
NS
PE
Membership
Will Expire
223.13
240.13
244.38
242.25
1-May-2015
Sept-2014
210.00
226.00
230.00
228.00
Oct-2014
275.63
296.63
301.88
299.25
1-May-2015
1-Nov-2015
Nov-2014
262.50
282.50
287.50
285.00
1-Nov-2015
Dec-2014
249.38
268.38
273.13
270.75
1-Nov-2015
Associate Insured Student Membership
Insurance Option 1 - Medical Malpractice & Commercial General Liability (CGL) Combined
Join
NHPC
Resident of
AB, BC, NT,
NU, SK, YT
Aug-2014
160.75
Resident of
Resident of
Resident of
Resident of
Resident of
Resident of
MB
QC
ON
NB, NL
NS
PE
Membership
Will Expire
167.31
168.13
173.31
166.75
168.25
167.50
1-May-2015
Sept-2014
152.75
158.67
159.41
164.67
158.75
160.25
159.50
1-May-2015
Oct-2014
197.75
207.27
208.46
213.27
203.75
205.25
204.50
1-Nov-2015
Nov-2014
188.75
197.55
198.65
203.55
194.75
196.25
195.50
1-Nov-2015
Dec-2014
179.75
187.83
188.84
193.83
185.75
187.25
186.50
1-Nov-2015
Membership
Will Expire
Insurance Option 2 - Medical Malpractice ONLY
Join
NHPC
Resident of
AB, BC, NT,
NU, SK, YT
Aug-2014
130.75
Resident of
Resident of
Resident of
Resident of
Resident of
Resident of
MB
QC
ON
NB, NL
NS
PE
134.91
135.43
140.91
136.75
138.25
137.50
1-May-2015
Sept-2014
125.75
129.51
129.98
135.51
131.75
133.25
132.50
1-May-2015
Oct-2014
154.75
160.83
161.59
166.83
160.75
162.25
161.50
1-Nov-2015
Nov-2014
148.75
154.35
155.05
160.35
154.75
156.25
155.50
1-Nov-2015
Dec-2014
142.75
147.87
148.51
153.87
148.75
150.25
149.50
1-Nov-2015
Associate Uninsured Student Membership
No fee. Student membership without insurance is complimentary.
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: growingtogether@nhpcanada.org
Page 6
of 7
Payment for Associate Membership
Including Student Liability Insurance
Payment Information (required)
Promo Code (if applicable)
Payment Amount
$
Make cheques payable to Natural Health Practitioners of Canada
Paying By
Money Order
VISA/MasterCard Number
Cardholder Name (Printed)
Cheque
Certified Cheque
Credit Card
Expiry Date (MM/YY)
Cardholder Signature
Non-Sufficient Funds
If you pay your member application fee by credit card and payment has been denied, we will contact you regarding alternate
payment options.
If the bank denies your cheque, a $50 processing fee will be assessed. Payment will only be accepted by money order or
certified cheque thereafter.
Refund Policy
The NHPC has a no refund policy. A non-refundable $200.00 (plus tax) processing fee will be charged for any withdrawn or
refused applications once submitted. Once the financial transaction is completed, there will be no reimbursement of fees.
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: growingtogether@nhpcanada.org
Page 7
of 7