Additional Insured Request Form

What is the purpose of an Additional Insured for MTAA members?
Clinics, employers, or landlords may require MTAA Active members to provide proof of being added to their liability policy as an Additional Insured. An Additional Insured provides the clinic, employer, or landlord confirmation that the Active member carries individual Professional (malpractice) and Commercial General Liability (CGL) coverage as a member of the MTAA. When a member requests the clinic, employer, or landlord to be added as an Additional Insured, they will receive confirmation of this change with a document that includes the additional clinic, or business information added to their liability policy.

Who can request a clinic, employer, or landlord to be added as an Additional Insured?
Only Active and New Active members in good standing can request for an Additional Insured to be added to their liability policy. Insured and Free Student members are not eligible to request an Additional Insured.

Members must ensure that they follow all steps before submitting their request. Those members who do not have the required information confirmed on their member portals will have their requests automatically turned down.

Step 1 – Update Member Portal
Update your member portal by adding the clinical details in the space labeled Clinic 1. The information submitted in the online form must match exactly what is shown as Clinic 1 in your member portal. If there is a discrepancy between the information shown as Clinic 1 in your member portal from that of what is provided in the online form, the MTAA will turn down your request for an Additional Insured.

If you are requesting an Additional Insured for your landlord or building management company you do not need to list the details in Clinics 1, 2, or 3.

Step 2 -Completed the Online Form.
If you wish to obtain an Additional Insured, please complete the online form. All requests can take 5 - 7 business days to process. Once your request has been processed, the MTAA will issue you a copy of the Additional Insured document to the email provided in the completed online form. The MTAA can only issue Additional Insureds directly to members. We will not issue these to other individuals or businesses on behalf of a member. 

MTAA Member Contact Information

Please provide your contact details and ensure they match the information listed in your member profile. 

If your email address or phone number has changed, please complete a profile update. 

REQUIRED

First Name*

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Last Name*

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Member Number*

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Email Address*


Re-enter to confirm

Confirm email doesn't match email.

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Phone Number*

Confirmation of Member's Residential Details

Please list your current residential address. 

It is important to note that this information must match the details listed in your member profile. If they do not, then please complete a profile update. 

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Address *

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City*

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Province *

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Postal Code*

Required Clinical Practice Details

Please list the address details for the clinic or landlord you wish to obtain an Additional Insured for. 

Please list the information exactly how you would like it to be displayed on the Additional Insured document.  

REQUIRED

Please indicate the reason for requesting an Additional Insured.*




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Clinic/ Company Name*

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Address*

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City*

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Province*

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Postal Code*

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Phone Number*

Important Note

All requests can take 5 - 7 business days to process. Once your request has been processed, the MTAA will issue you a copy of the Additional Insured document to the email provided in the completed online form.

If you have any questions about obtaining an Additional Insured, please contact our office by calling 403-340-1913 or by emailing info@mtaalberta.com

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