BCACC 2017 Online Application - April 1, 2017-2018
For online enrollment, you must complete the application form below and proceed to the PayPal payment gateway using the "Submit" button at the bottom of the screen to pay securely by credit card or PayPal account. (PayPal's credit card option is at the bottom of their payment screen).

To ensure proper processing of your application and payment, specific information from your application, along with the amount owing, will be transferred to the PayPal payment form, and must not be changed.
  • General Information

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  • Please provide a valid email for correspondence. This email must be used in the following payment screen for payment matching purposes.
  • Please use Province acronym (for example, BC for British Columbia)

    Postal Code (Format L0L 0L0 with Capital Letters)
  • (This is typically a 4-5 digit number found on your membership card. Please fill in the number exactly as you see it. DO NOT USE LEADING ZEROES!)
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  • WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE INSURER, IT IS AGREED THAT IF THERE BE KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY CLAIM OR ACTION SUBSEQUENTLY EMANATING THEREFROM IS EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE.
  • To Enroll

    Select the required coverage & limit for your needs from the options below. Coverage will be affected upon approval of application and receipt of payment in the amount of the total premium.

    Coverage may be delayed until after your application has been approved by The Mitchell & Abbott Group.
  • Professional Liability includes a $20 administration fee.
  • Commercial General Liability includes a $10 administration fee.
  • Limit of insurance per occurrence.
  • Terms & Conditions

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

    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.

    DECLARATIONS AND SIGNATURE

    The undersigned Applicant for this insurance declares that, to the best of his/her 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. The undersigned further agrees 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.

    Although the signing of this Application form does not bind the Applicant to purchase the insurance, the undersigned Applicant agrees that this form and the information furnished pursuant hereto shall be the basis of the contract should a policy be issued and this form will become part of the policy.
    It is also agreed that should a policy be issued, it is understood that eligibility for this program is contingent upon membership in good standing in the B.C. Association of Clinical Counsellors.
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  • To ensure proper processing of your application and payment, specific information from your application, along with the amount owing, will be transferred to the PayPal payment form, and must not be changed. Please enter your payment information to complete the application.

    If you would like to print a copy of your completed form before submitting, please do so now: Print Completed Form

    Please only press the SUBMIT button once. You will be redirected to your PayPal payment screen.

    IF YOUR FORM DOESN'T SUBMIT YOU MAY HAVE MISSED A REQUIRED FIELD. PLEASE REVIEW YOUR FORM AND FILL OUT REQUIRED FIELDS.