Individual Membership Form

Individual Membership Form

If you require membership and professional liability insurance for the period May 15th to June 30, 2021 please email the office at info@pharmacistsmb.ca.


Personal Information

Membership Detail

Membership prices shown do not include GST.

Online registration for the 2020/2021 membership year has been suspended. If you require membership and professional liability insurance for the period April 1st to June 30, 2021 please email the Pharmacists Manitoba office at info@pharmacistsmb.ca to have your application processed manually.


View our refund policy here

(Optional) Please provide us with your licence number.

Please indicate whether you are interested in volunteer opportunities with Pharmacists Manitoba.

Donations

The Public Relations Fund is used to consistently promote a strong, positive image of pharmacists to the public and stakeholders through the design, marketing, promotion and delivery of communication campaigns that are developed in partnership with stakeholders. In 2021 our public relations messaging has focused on the role of pharmacists during the COVID-19 pandemic and the importance of pharmacists as front line healthcare providers during this crisis. In order to promote pharmacists and their role in providing front-line healthcare services we are requesting that all pharmacists contribute $50 each to the Public Relations Fund. If you would like to donate an amount other than $50 please enter it below. The donation is completely voluntary.

The Friends of Pharmacy Fund is used to promote certain special interests concerning pharmacy.

Professional Liability Insurance Add-On

The Manitoba Pharmaceutical Act Regulations require all licensed pharmacists be covered by professional liability insurance that provides a minimum of $2,000,000 per claim or per occurrence and a minimum $4,000,000 annual aggregate.

Choose your level of professional liability insurance provided by the Canadian Pharmacists Benefits Association. Please read through the options carefully and select your level of coverage.

PLEASE REVIEW THE FOLLOWING THREE STATEMENTS BELOW AND ANSWER BELOW WHETHER ANY APPLY

  1. Has any application for Professional Liability insurance ever been denied or cancelled?
  2. Have you ever sustained a Professional Liability loss or has such a claim been made against you in the last five years?
  3. Have you any knowledge of any negligent act, error or omission or breach of duty which might give rise to a claim against you?

If you have answered "YES, one or more apply to me" to the question above, please continue with your membership renewal by selecting the "I Decline" insurance option above. CPBA’s insurance program broker, BMS Canada Risk Services Ltd., will facilitate the insurance component of your purchase. Please contact BMS at cpba.insurance@bmsgroup.com to review your insurance application and they will assist you in securing coverage under the CPBA program

DECLARATION REVIEW

I declare that during the last five years no insurer has cancelled, declined or refused to issue me any form of liability insurance and that this application discloses the hazards known to exist at the date of this application. I declare that the statements made herein are in every respect true and correct and hereby apply for a contract of insurance to be based upon the truth of the said statements.

Submitting this form does not bind the Applicant or company to complete the insurance but is agreed that this form shall be the basis of the contract should a policy be issued. The insurance premium is fully retained and not refundable.

I understand that if no insurance selection is made above that I have opted not to have insurance coverage through CPBA as part of my Pharmacists Manitoba membership.

APPLICANT’S CONSENT TO THE TRANSMISSION OF THE INFORMATION CONTAINED IN THE APPLICATION

I hereby acknowledge that the information collected in the Application form is acquired by my insurance broker to be transmitted to the insurer for the sole purpose of obtaining an insurance policy, and will be kept confidential.

I consent to be contacted directly by e-mail by BMS Canada Risk Services Ltd. concerning the professional liability insurance coverage (primary and supplementary), they make available to me through the Canadian Pharmacists Benefit Association and Pharmacists Manitoba, and my eligibility and application for, and renewal of, such insurance coverage. I understand that I may withdraw this consent at any time.

ADDITIONAL QUESTIONS FOR SUPPLEMENTARY INSURANCE

Limits $3,000,000 per claim / $5,000,000 aggregate
Deductible: $0

Declaration: I declare that to the best of my knowledge and belief, the statements set forth herein are true and correct and that reasonable efforts have been made to obtain sufficient information to facilitate the proper and accurate completion of this application form. I further agree that if any significant change in the condition of the applicant is discovered between the date of this application form and the effective date of the policy, which would render this application form inaccurate or incomplete, notice of such change will be reported immediately in writing to the Insurance Manager.