CANADIAN PHARMACEUTICAL SPECIFIED PRODUCTS SUPPLEMENT PLEASE ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE “N/A” - IF SPACE IS INSUFFICIENT PLEASE USE SEPARATE SHEETS UNLESS IT IS SPECIFICALLY AGREED WITH UNDERWRITERS COVER PROVIDED MAY EXCLUDE ANY LIABILITY ARISING OUT OF THE FOLLOWING.
Please check the Products which would apply to your operations.
Agent Orange – Dichlorophenoxyacetic Acid (2, 4-
D) and Trichlorophenozyacetic Acid (2, 4,5t) Alosetrin
Any product that does not have regulatory
Dexfenfluramine Fenfluramine or Phentermine
Dicyclomine when give to children under 4 years
Ephedra Sinica Ephedra Extract Ephedra Herb
Powder Epitonin or any derivative thereof
(i) The concomitant or combined use of two or
(ii) Rhabdomyolysis arising out of either of the
Hormone Replacement Therapy of Animal Origin
Contraceptives (including birth control pills)
fertility drugs and products specifically designed
and marketed for use during and in connection
Latex &/or latex protein &/or latex derivatives
&/or latex substances howsoever the latex, latex
protein, latex derivatives or latex substances are
named, identified, described or classified Leflunomide
Silicone – any product containing silicone which is
in any form implanted or injected in the body
2, 3, 8 – Tetrachlorodibenzo-p-dioxin (2, 3, 7,
Tobacco or any tobacco products (or ingredients
Urea Formaldehyde or any products containing
For the products checked in the above list please provide full details as follows:
Are products supplied on a Named Patient Basis only or in accordance with
If Yes, please provide details of licence held:
Product details enclosing Data Safety Sheets where possible.
If manufactured, to whose formula/specification?
If marketed only, are rights of recourse maintained against manufacturers/suppliers?
How long have you marketed or manufactured the products?
Estimated annual turnover per specific product:
If exports involved details of territories to be supplied and estimated turnover:
THE UNDERSIGNED HEREBY ACKNOWLEDGES THE TRUTH OF THE STATEMENTS CONTAINED HEREIN.
I AUTHORIZE YOU TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION AS PERMITTED BY LAW, IN
CONNECTION WITH YOUR COMMERCIAL INSURANCE POLICY OR A RENEWAL, EXTENSION OR VARIATION THEREOF,
FOR THE PURPOSES NECESSARY TO ASSESS THE RISK, INVESTIGATE AND SETTLE CLAIMS, AND DETECT AND
PREVENT FRAUD, SUCH AS CREDIT INFORMATION, AND CLAIMS HISTORY.
For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Lloyd’s Underwriters’ insurance business in Canada.
THE COMPLETION AND SIGNATURE OF THIS FORM DOES NOT BIND THE PROPOSER OR UNDERWRITER TO COMPLETE A CONTRACT OF INSURANCE UNLESS SPECIFIC AGREEMENT IS GIVEN BY BOTH PARTIES. THIS FORM MUST BE SIGNED BY A PARTNER OR DIRECTOR OR AUTHORIZED SIGNATORY OF THE FIRM.
Signature of Applicant (authorized representative)
For contact information visit: www.elliottsr.com
AJSM PreView, published on May 13, 2009 as doi:10.1177/0363546509334374 Home Training, Local Corticosteroid Injection, or Radial Shock Wave Therapy for Greater Trochanter Pain Syndrome Jan D. Rompe,*† MD, Neil A. Segal,‡ MD, Angelo Cacchio,§ MD, John P. Furia,ll MD, Antonio Morral,¶ PT, and Nicola Maffulli, MD, MS, PhD, FRCS(Orth), FFSEM(UK) From the † OrthoTrauma Evaluation Cent
Yom Kippur 5770: Keys, Lost and Found Rabbi Lisa Grushcow, Congregation Rodeph Sholom “Today I am a fountain pen.” Even before that phrase was born, we asked the timeless question: “What does it really mean to become a Jewish adult?” When thirteen year-olds come into my study to work on their speeches, I try to ask them as well. “After all,” I tell them, “it’s not as if y
CANADIAN PHARMACEUTICAL SPECIFIED PRODUCTS SUPPLEMENT