Individual Access to CNPS Services APPLICATION FORM
Individual Access to CNPS Services
APPLICATION FORM
IMPORTANT: This form is for use by registered nurses and nurse practitioners who have a valid licence or registration to practise nursing in Ontario, Quebec and British Columbiaand who are currentlynot eligible for CNPS services. Nurses licensed in other Canadian provinces or territories, including RNAO members in Ontario,are already eligible for CNPS services. Eligible nurses are referred to as “CNPS Beneficiaries”.
Registration Period: January 1, 2015 to December 31, 2015
Eligibility for CNPS services, including professional liability protection,shall commence on the day CNPS receives your completed application,provided payment is included.
CNPS 2015 annual fees:
☐Registered Nurse (RN): $150☐Nurse Practitioner (NP): $330
Plus applicable taxes: ON 13%, QC 14%, BC 5%
First name / Initial / Lastname
Permanentaddress / Date of birth (yyyy/mm/dd)
City / Province / Postalcode
Is your mailing address the same as your permanent address? ☐yes, same as above
Mailing address (if different than permanent address)
City / Province / Postal code
Home phone / Work phone / Cell phone
Email address (The use of a personal email address is recommended.)
Information and consent related to the use of email communications
The CNPS will use your email address for transactional purposes, such as confirming receipt of your application form, confirming successful completion of your registration, initiating the renewal process and, if requested, providing written confirmation of eligibility for CNPS professional liability protection. The CNPS may also use your email address to appropriately respond to your inquiry(ies) or request(s) for CNPS services if, at that time, this has been identified as your preferred mode of communication or to establish contact with you in reference to an inquiry(ies) or request(s) for CNPS services, if your preferred mode of communication has failed. By completing this form, you consent to your email address being used for these purposes.
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The CNPS may also, with your consent, use your email address to provide you with other relevant forms of electronic information from the CNPS, including, but not limited to, information about webinars, events, legal developments and publications.
I give my consent to CNPS to use my email address to provide me with such other relevant information.
I consent ☐ I do not consent ☐
I understand I may remove my consent from the CNPS to use my email address for information purposes at any time by selecting the UNSUBSCRIBE feature that accompanies the communication or by contacting CNPS directly.
In which province(s) or territories are you licensed or registered to practise nursing? (check all that apply)
Province / Territory of Work / Registration/License Number / Class of Registration
☐Alberta* / ☐RN ☐NP ☐Other:
☐British Columbia / ☐RN ☐NP ☐Other:
☐Manitoba* / ☐RN ☐NP ☐Other:
☐New Brunswick* / ☐RN ☐NP ☐Other:
☐Newfoundland and Labrador* / ☐RN ☐NP ☐Other:
☐Nova Scotia* / ☐RN ☐NP ☐Other:
☐Northwest Territories/Nunavut* / ☐RN ☐NP ☐Other:
☐Ontario* / ☐RN ☐NP ☐Other:
☐Prince Edward Island* / ☐RN ☐NP ☐Other:
☐Quebec / ☐RN ☐NP ☐Other:
☐Saskatchewan* / ☐RN ☐NP ☐Other:
☐Yukon* / ☐RN ☐NP ☐Other:
*If you have selected any province or territory indicated by an asterisk* you are alreadyeligible for CNPS assistance providing you are currently a practising registered nurse or nurse practitioner.
Practising in Ontario? RNAO members arealready eligible for CNPS services. Nurses practising in Ontario can also apply to become a beneficiary by completing this registration form.
If you practise in more than one jurisdiction, which province or territory do you practise in the most?
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Employment InformationAre you currently an employee? /
☐yes ☐no
If yes, does your employer also provide you with professional liability protection?
☐yes how much?
☐no ☐unknown
Are you an independent contractor? / ☐yes ☐no
If yes, do you have other sources of professional liability protection?
☐yes how much?
☐no ☐unknown
Note: If your employer withholds income tax and other at source deductions, you are probably an employee. If your employer does not withhold income tax and other source deductions or if you provide nursing services as the owner of a professional corporation or other business entity, you are likely an independent contractor.
Certification and Acceptance of Terms
I hereby certify that the statements and information in this registration form aretrue and correct to the best of myknowledge and belief. I authorize the Canadian Nurses Protective Society (CNPS) to investigate all statementsor other informationcontained in this registration form and anyattachments submitted with it.
I understand and agree that any misrepresentation, falsification or material omissionof information on this form may result in denial or revocation of my beneficiary status with the CNPS.
I have read the CNPS Bylawsand understand my obligation to cooperate with the CNPS and report any claim or adverse event to CNPS at the earliest opportunity. I acknowledge that CNPS financial assistance is discretionary and will be granted on a case by case basis.
I understand that CNPS services and, in particular, the provision of professional liability protection and legal assistance does not generally extend to my professional corporation or business entity.
Name or signature of applicant / Date (yyyy/mm/dd)
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Please return your completed form to the Canadian Nurses Protective Societyusing one of the following:
Email:
Mail:1545 Carling Avenue, Suite 510
Ottawa ON K1Z 8P9
Fax:613-237-6300
To become an eligible beneficiary of CNPS services, you must submit a completed application form andelectronic payment. Your eligibility for CNPS professional liability protection and legal assistance will be conditional upon having a valid license or registration to practice nursing at the time of the events giving rise to your inquiry, a claim or legal proceeding. Please allow 10 business days to process your application.
Email notification: CNPS will send you an email confirming receipt of your application form and a confirmation of payment and eligibility for CNPS services, once your registration has been successfully processed.
Do you wish to receive a letter confirming your eligibility for CNPS professional liability protection?
If your employer, a health care institution or other third party has required evidence that you have in place adequate liability protection, you can obtain from the CNPS a letter confirming your eligibility for the CNPS professional liability protection. You can request such letter at any time by contacting the CNPS at 1-844-4-MY-CNPS (1-844-469-2677) or by presenting a request by email at .
If you require more information, please contact the CNPS at 1-844-4-MY-CNPS (1-844-469-2677).