Holman Insurance Brokers Ltd.
HOLMAN
INSURANCE BROKERS LTD.
3100 Steeles Ave. East, Suite #101, Markham Ontario Canada L3R 8T3
Telephone: 905-886-5630 Toll Free: 1-800-567-1279 Fax: 905-886-5622
Website: www.holmanins.com
E-mail: service@holmanins.com
COMMERCIAL PROPERTY APPLICATION
INSURED INFORMATION
Full Name of
Insured (full legal
name):
Mailing Address:
Street:
City:
Province:
Risk Location
Address:
Postal Code:
Street:
City:
Province:
Postal Code:
BUS TELEPHONE:
Name of
Principal(s):
FAX:
______________________________________________
__________________________
____________________
CELL:
EMAIL:
WEB ADDRESS:
__________________________
____________________________
_____________________________________
BUSINESS OPERATIONS
Description of
Operations:
Sales/Receipts
$_____________ Canadian
Payroll
$_________________
$_____________USA
$___________ Other Countries
# of Employees _______
# of Sub-Contractors (if any) ______
Number of Years in Business:
PLEASE ATTACH A COPY OF YOUR EXPIRING POLICY.
INSURANCE HISTORY
Current Insurer:
Expiry Date
Policy #
Expiring Premium
$
Previous insurance cancelled, declined or non-renewed
in the last 10 years?
YES or
YES or
Any Claims in Last 10 years?
Date
HIBL SF 06/12 app
Description
NO
If yes, please explain
NO If yes, provide full details including date
of loss, description and the amount paid.
Amount Paid
Open or Closed
Page 1 of 3
RISK INFORMATION
Building Type:
Construction
Roof:
High Rise
Enclosed Mall
Strip Plaza
Industrial Mall
Stand Alone
Other
Fire Resistive
Non-Combustible with Masonry Walls
Non-Combustible with non-masonry walls
Masonry
Masonry Veneer
Frame and all other
Reinforced Concrete
Steel Deck
Wood Joist
Corrugated Metal, Steel
Truss
Heating:
Electrical System:
Forced Air
Gas
Oil - Age of tank________
Other
Fuses
Breakers
Supply
Copper
Cast Iron
Plumbing:
Number of Stories:
(Exclude
basement)
Heavy Timber
No of AMP________________
ABS
Galvanized
_______
No. of Units _________________
________
Sq. Ft or
Other Occupancies in the Building:
Sq. Ft or
If over 35 years old have updates been carried out:
YES or
NO
______ Metres
Neighbouring Exposure:
To Left:
Retail Store
NO
NO
Wiring: ______
Distance to Hydrant:
Total square meters of building(ground
floor):_______________
Restaurant/Bar
Industrial/Commercial
YES or
Heating: ______
YES or
Pex
Copper
Sq. Metres
Office
Manufacturing
Basement:
Sprinklered:
ABS
Galvanized
Sq. Metres
______
If updated, what year:
Air Conditioning
Roof Top
Other
Drain
Copper
Cast Iron
Pex
Copper
Area Occupied by Insured: _____________
Year Built:
Electric
Roof: ______
Plumbing: ______
If yes, percentage sprinklered: ______%
Distance to Fire Hall: ______ km
To Right:
Front:
Behind:
PROTECTION INFORMATION
Fire Alarm:
None
Local
Monitored (attach certificate)
ULC Certified (attach certificate)
Burglar Alarm
None
Local
Monitored (attach certificate)
ULC Certified (attach certificate)
Extent of Protection:
Perimeter
Motion Sensors
Line Security
HIBL SF 06/12 app
YES or
NO
If yes, specify:
Page 2 of 3
COVERAGE REQUIREMENTS
PROPERTY COVERAGE – DEDUCTIBLE MINIMUM IS $1,000
Building
Office Contents
Equipment (Including Tenants Improvements)
Stock
Transit
Business Interruption
Loss Rent / Rental Income
Extra Expense
Equipment Breakdown
Computer (Hardware / Software)
Earthquake
Flood
Sewer Back up
Condo Unit Owner
Yes or
No
Select if required and state
amount required under
Amount of Insurance ▼
AMOUNT OF
INSURANCE
$
$
$
$
$10,000
$10,000
$
$25,000
$100,000
$
Included
Included
Included
Included
Subject to deductible of $50,000 minimum
Subject to deductible of $25,000
Subject to deductible of $2,500
Condo Loss Assessment
Yes or
No
CRIME COVERAGE – DEDUCTIBLE MINIMUM IS $1,000
Crime Package Form
$2,500
COMMERCIAL GENERAL LIABILITY COVERAGE
AMOUNT OF
INSURANCE
Available Limits (check one)
►
Bodily Injury and Property Damage
Bodily Injury and Property Damage
Products-Completed Operations
Personal and Advertising Injury Liability
Personal and Advertising Injury Liability
Medical Payments
Medical Payments
Tenant’s Legal Liability
Employee Benefit Liability
Non Owned Automobile Extension SPF#6
$1,000,000
$2,000,000
Each Occurrence
Aggregate $5,000,000
Aggregate $5,000,000
Each Occurrence
Aggregate
Per Person
Aggregate
Subject to deductible $1,000
Subject to deductible $1,000
Subject to deductible $1,000
$5,000,000
▼
$
Included
Included
$1,000,000
$1,000,000
$10,000
$25,000
$500,000
$1,000,000
$1,000,000
This is only an application and does not constitute an insurance policy. Insurance shall become effective only on issuance of a
policy or written binder specifically authorized by the company or agency. Quotations will be based upon the information provided
and the applicant warrants information provided.
DECLARATION
You must read this before signing below.
To the best of my knowledge and belief the information provided in connection with this application, whether in my own hand or not,
is true and I have not withheld any material facts. I understand that non-disclosure or misrepresentation of a material fact will entitle
underwriters to avoid this insurance.
PRIVACY ACT CONSENT
Consumer and previous insurer reports containing personal, credit, factual, investigative or previous claim and loss information
about the applicant may be sought in connection with this application for insurance or a renewal, extension or variation thereof.
All provisions contained in the various forms issued under this contract shall be deemed to be contained in the present application
for insurance. The answers in all parts of the application are correct to the best of my knowledge and belief.
Signature of Applicant
Date
Print Name
You must inform us of any change in circumstances which will materially affect this insurance.
HIBL SF 06/12 app
Page 3 of 3
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