APPLICATION FOR COMMERCIAL GENERAL INSURANCE

APPLICATION FOR COMMERCIAL GENERAL INSURANCE
APPLICATION FOR COMMERCIAL GENERAL INSURANCE
1.
2.
3.
4.
5.
6.
7.
Name of Broker:
Phone Number:
Name of Insured:
Contact Person:
Mailing Address:
Name of Event:
Location of Risk:
Occupancy:
8.
9.
10.
Other Occupancy(ies):
Website:
Loss Payee / Morgagee
11.
Policy Term:
12.
Expiry date of prior coverage if different from effective date listed above:
13.
COVERAGES:
Fax Number:
Title:
Phone Number:
From:
To:
PROPERTY
Fire
Replacement Cost
Building
Equipment
Stock
Business Interruption
Form:
Rents
Named Perils
Actual Cash Value
Amount of Insurance
Co-Insurance
$
$
$
$
$
$
$
$
$
$
$
$
100
Broad Form
Rate
Deductible
Premium
%
%
%
%
%
$
$
$
$
$
$
$
$
$
$
%
%
%
%
%
%
%
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Other:
BURGLARY AND ROBBERY
Comprehensive Dishonesty, Disappearance & Destruction Rider
I Commercial Blanket Bond, Form A
II Loss Inside (10% overnight limitation when not kept in safe)
III Loss Outside
IV Money Orders and Counterfeit Paper Currency
V Depositors Forgery
May 1, 2013
$
$
$
$
$
$
$
$
$
$
Page 1 of 4
Broad Form Money & Securities (10% overnight limitation when not kept in safe)
Inside/Outside Robbery
Damage to Building by Burglary
Description of Safe:
Is there an ATM at any of the Insured’s premises
Yes
No
If yes, Details:
LIABILITY
$
$
$
$
$
$
(Supplementary questionnaires may be required for certain types of risks)
Commercial General Liability
General Aggregate Limit
Occurrence Limit
Personal & Advertising Injury Limit
Products & Completed Operations Aggregate
Tenants Legal Liability
Medical Payments
Property Damage Deductible
Reimbursement Clause
Non Owned Automobile
Other:
Limit
5,000,000
1,000,000
1,000,000
1,000,000
100,000
10,000
$
$
$
$
$
$
$
$
$ 1,000,000
$
$
$
$
$
or
or
or
or
or
per occurrence or
per claimant
or
PAYROLL (Indicate number of employees)
$
RECEIPTS (Indicate split between operations and include percentage of
U.S. and Foreigh Sales if applicable)
$
$
$
$
Please provide complete details of all operations. If more space is required, please attach additional details:
(if any liquor sales, provide the percentage and information regarding staff training in an intervention and awareness program. Include
procedures of how intoxicated patrons are handled)
Additional Insureds: (list name, mailing address and interest):
BLANKET GLASS
Dimensions:
Description:
Deductible:
Broad Form
EQUIPMENT BREAKDOWN COVERAGE
Air Condition:
Limit per accident:
Perishable Stock Limit:
14.
Yes
No
$
Comprehensive Form
Details:
$
$
UNDERWRITING INFORMATION – please attach photo of risk
Building Construction
Age of Building:
Exposing Property:
Area (check all that apply)
May 1, 2013
Height:
Wall Construction:
Roof Construction:
Story(ies)
Square footage:
North:
industrial
South:
commercial
by insured;
East:
residential
agricultural
by others
West:
urban
suburban
rural
Page 2 of 4
Upgrades (if older than 30 years
Roof:
Yes
No
Plumbing:
Yes
No
Heating:
Yes
No
Electrical:
Yes
No
Sprinklered:
Yes
No
Heating:
natural gas
forced air
Electricity:
fuses
Hydrant Protected:
Fire Department:
Details:
Details:
Details:
Details:
Date:
Date:
Date:
Date:
lp gas
oil
hot water
radiant
non interchangeable breakers
Yes
within
No
electric
steam
within
Other:
Other
Wiring:
feet /
miles /
meters of premises
kilometers
Does this business depend on any key equipment which may be difficult to replace?
Yes
No
If yes, please explain:
RETAIL RISKS:
Is there any food prepared or cooking done?
Yes
No
If yes, provide details:
Yes
No
Is there a deep fat fryer or grill?
Describe automatic extinguishing system:
Yes
No
Maximum Amount:
Any Tobacco or Liquor Products sold?
If yes, provide details of storage and cages:
Is there a floor maintenance program in place?
Yes
No (please attach copy)
Are daily sweep logs kept?
Yes
No
15.
$
BURGLARY / THEFT PROTECTION – attach alarm certificate from monitoring company if applicable
Central Station Monitored
Local Alarm
Monitored (other)
ULC listed
All Open Areas Covered
Other:
Name of Monitoring Company:
Name of Alarm System:
Full Perimeter
Motion Detectors
All Open Areas Covered
Back Up (cellular)
Heat / Smoke Sensor
Roll Down Shutters
Tape on all Windows
Bars on Windows (front)
Bars on Windows (rear)
Infra Red
Entry Barriers
Deadbolt Locks on doors
Bars on Doors
Contacts on all Doors
Security Guard(s)
Insured has been in business
years; or
This is a New Venture.
If this is a new venture, describe the principals prior business experience:
16.
PREVIOUS INSURANCE AND LOSS HISTORY
Previous Insurer(s):
Policy Number(s):
Expiring Premium (if known):
Does Wynward Insurance Group have any other related business for this applicant?
If yes, provide name and policy number:
Yes
No
Has any Insurer cancelled or declined to renew a policy of insurance for this applicant?
If yes, explain:
No claims or incidents in the last 5 years of operation.
No claims or incidents – New Venture
Unknown – no prior insurance
Claims / incident history (5 years):
Amount Paid
Expenses
Date of Claim
Description
Any uninsured losses in the past 5 years?
If yes, explain:
May 1, 2013
Yes
Deductible
No
Page 3 of 4
17.
BROKER RECOMMENDATION
New Business to your broker office
Currently insured through your broker office
If currently insured through your office, why is the account being re-marketed?
Is applicant known to selling broker?
If yes, for how long?
Has marketing broker seen this risk?
If yes, what is the condition of this risk?
Attach photo of risk
Any visible damage to risk?
If yes, explain:
unknown
Financial Situation of applicant
Marketing brokers overall opinion of risk:
Completed by:
Yes
No
Yes
No
excellent
Yes
good
average
fair
good
good
average
average
fair
fair
poor
No
excellent
excellent
Agency / Brokerage:
poor
poor
Date:
________________________________________ ________________________________________________ _____________________
18.
CONSENT in accordance with the Act Respecting the Protection of Personal Information
If it should be necessary for the purpose of my file, I, undersigned, the applicant specifically consent that my broker and my insurers, for the
time required to fulfill their functions:
(A) Gather all the pertinent necessary information from the holders of my prior insurance files, intermediaries in the insurance industry,
insurance companies, financial institutions, credit agencies, government records establishing driving experience, prevention, detection, or
repression of crime agencies and institutions that gather and compile data on insurance risks and losses.
-
for the purpose of establishing the premium and the assessment of risk; and, (if you would like to consent now)
for the purpose of verification, assessment and the settlement of losses;
Furthermore, I authorize my broker to sign on my behalf any request or form that may be necessary in order to gather information concerning
me.
(B) Disclose, in the case of my broker, the information obtained to insurers with whom he is doing business; when it is my insurers, to
institutions that gather and compile data on insurance risks and losses and prevention, detection or repression crime agencies. Solely the
employees, mandatories or representatives of my broker, insurers or of institutions referred to in this paragraph will have access to this
information when required within the execution of their functions.
Furthermore, I consent that holders of information concerning me and covered by the present consent be released from their confidentiality
undertaking and that they convey the required information to my broker, my insurers, their employees, trainees or representatives.
I acknowledge having been informed of my right to access to information obtained by virtue of the present consent and to have it corrected, if
need be.
Furthermore, I acknowledge having been informed that I may address all questions regarding the present consent to my broker and/or my
insurers, their employees, trainees or representatives.
This insurance application is considered to include all provisions for all forms to be issued in accordance with this contract.
The total estimated policy premium is subject to adjustment.
SIGNATURE OF APPLICANT
May 1, 2013
DATE
SIGNATURE OF CO APPLICANT
DATE
Page 4 of 4
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