Professional Engineers
Ontario
Sampfe Disclosu,re Notice
The Professional Engineers Act and the Regulations thereunder require that each holder of a
Certificate of Authorization be insured against professional liability in accordance with specified
minimum requirements. As an alternative, the Certificate of Authorization holder is required to
give notice to each person to whom the holder provides services within the practice of
professional engineering, stating that the holder is not insured in accordance with guch
minimum requirementsl This notice is given to you in compliance with this legislation.
THE UNDERSIGNED HEREBY ADVISES YOU THAT THE UNDERSIGNED IS NOT INSURED
FOR PROFESSIONAL LIABILITY IN ACCORDANCE WITH THE MINIMUM REQUIREMENTS
OF ONTARIO REGULATION 941 MADE UNDER THE PROFESSIONAL ENGINEERS ACT.
DATED this day of ,20
(Signature of Professional Engineer
representing the holder of the
Certificate of Authorization)
The legislation referred to above requires this disclosure notice to include Estatement to be
signed by the person (the client) to whom the services are to be provided, to the effect that the
client understands that the Certificate of Authorization holder is not so insured. The legislation
also requires the holder to receive from such client written authority to provide those services
without that insurance. ln compliance with this legislation, please sign the statement set forth
below on both copies of this disclosure notice and return one copy to us.'
THE UNDERSIGNED ACKNOWLEDGES RECEIPT OF THIS DISCLOSURE NOTICE AND
CONFIRMS THAT THE UNDERSIGNED UNDERSTANDS THAT THE ABOVE IS NOT INSURED
IN ACCORDANCE WITH THE MINIMUM REQUIREMENTS DESCRIBED ABOVE AND
CONFIRMS THAT THE ABOVE HAS THE WRITTEN AUTHORITY TO PROVIDE
PROFESSIONAL ENGINEERING SERVICES TO THE UNDERSIGNED WITHOUT THAT
INSURANCE.
DATED this day of 20
(Signature of Client)
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