Individual Membership Form

Individual Membership Form

If you require membership and malpractice insurance for the period April 1st to June 30, 2016 please call the office at 204-956-6681.

Personal Information

Membership Detail

Membership prices shown do not include GST.

(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.This year, Pharmacists Manitoba is requesting that all pharmacists contribute $50 each to the Public Relations Committee. If you would like to donate an amount other than $50 please enter it below. The donation is completely voluntary.

Proceeds from the Friends of Pharmacy Fund are used to pursue certain special issues of concern to pharmacy in Manitoba. Please enter an amount below if you wish to donate to the Friends of Pharmacy Fund.

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.

If you have answered YES to the question above, you must provide Pharmacists Manitoba with all supporting documentation including: Statement of Claim, Description of any Circumstances and Insurance documentation, i.e. Loss Runs, Insurance Policies and Claims Resolution documentation. Please note that if this supporting documentation is not provided, you risk not being covered. Please contact Pharmacists Manitoba at info@pharmacistsmb.ca for additional information. If this is a new application for coverage, you agree that any such claims, or incidents or circumstances which may lead to a claim, are excluded from this proposed coverage whether or not disclosed.

I declare that the above statements and particulars are true and that I have not omitted or suppressed or misstated any material facts. 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 ENCON Group Inc. for the sole purpose of obtaining an insurance policy, and will be kept confidential.

Moreover, I authorize ENCON Group Inc., its insurers or service providers to:

  • conduct verification, using outside sources, of the information contained in the Application form, in attached documentation and in subsequently provided documentation;
  • in the event of a claim, transmit the submitted and verified information to loss adjusters, lawyers or other similar offices for the purposes of investigating, defending, negotiating or settling any claims, as required.

For more information on ENCON’s privacy policy, please contact privacy-officer@encon.ca.

I consent to be contacted directly by e-mail by Marsh Canada Limited and/or ENCON Group Inc., concerning the professional liability insurance coverage (primary and complementary), 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 COMPLEMENTARY 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.