INSURANCE APPLICATION FOR THE CANADIAN …...(including Exterior Signs and Electronic Data...
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CDECA Insurance Program New Business Application (07 27 16) Page 1 of 7 PROLINK Insurance Group Inc. | 480 University Ave. Suite 800 Toronto ON. M5G 1V2 | TF: 800 663 6828 | F: 416 595 1649 | E: [email protected] INSURANCE APPLICATION FOR THE CANADIAN DECORATORS’ ASSOCIATION (CDECA) New Business Application SECTION 1: APPLICANT INFORMATION PLEASE READ CAREFULLY: THIS IS AN APPLICATION FORM FOR A CLAIMS MADE POLICY. All questions must be answered completely. If there is no answer, write “none” or “n/a” in the space provided. Where space provided is insufficient to fully answer, please use separate page. 1. Name of Business: 2. Are you incorporated? ❏ YES ❏ NO 3. CDECA Membership Number: 4. Name of the Principal / Owner of the Business: Phone #: Fax #: Email: Mailing Address: City: Province: Postal Code: Website Address: 5. Do you rent, lease or own office space? ❏ YES ❏ NO SECTION 2: UNDERWRITING DETAILS 6. Please complete the following table: Please indicate the types of decorating services your firm provides to your clients and the estimated revenues from each service. Please indicate $0 if your firm does not provide the service listed and/or if a subcontracting firm is performing the service. Service Provided Estimated Revenues for the Next 12 Months Residential Decorating Services: $ Commercial Decorating Services: $ Electrical Services: $ Plumbing Services: $ General Contracting Services: $ Landscape Design Services: $ * Structural Design Services: $ Actual Construction, Installation, or Erection: $ ** Product Sales Manufactured by a Third Party: (please list types of products and revenue breakdown below) $ ________________________________________________________ $ ________________________________________________________ $ Other: __________________________________________________ $ *NOTE: Please request the supplemental designer application from PROLINK if you provide structural design services. **NOTE: If you are purchasing CGL coverage and your product sales make up more than 50% of your total revenues then you MUST purchase products liability coverage under Option D on page 3 of this application.
Transcript of INSURANCE APPLICATION FOR THE CANADIAN …...(including Exterior Signs and Electronic Data...
CDECA Insurance P rogramNewBus iness App l i ca t ion (07 27 16 ) Page1of7
PROLINKInsuranceGroupInc.|480UniversityAve.Suite800TorontoON.M5G1V2|TF:8006636828|F:4165951649|E:[email protected]
INSURANCEAPPLICATIONFORTHECANADIANDECORATORS’ASSOCIATION(CDECA)NewBusinessApplication
SECTION1: APPLICANT INFORMATION PLEASEREADCAREFULLY: THISISANAPPLICATIONFORMFORACLAIMSMADEPOLICY.Allquestionsmustbeansweredcompletely.Ifthereisnoanswer,
write“none”or“n/a”inthespaceprovided.Wherespaceprovidedisinsufficienttofullyanswer,pleaseuseseparatepage.1. NameofBusiness: 2. Areyouincorporated? ❏ YES❏ NO3. CDECAMembershipNumber: 4. NameofthePrincipal/OwneroftheBusiness:
Phone#: Fax#: Email:
MailingAddress:
City: Province: PostalCode:
WebsiteAddress: 5. Doyourent,leaseorownofficespace? ❏YES❏NO
SECTION2: UNDERWRITINGDETAILS 6. Pleasecompletethefollowingtable:
Pleaseindicatethetypesofdecoratingservicesyourfirmprovidestoyourclientsandtheestimatedrevenuesfromeachservice.Pleaseindicate$0ifyourfirmdoesnotprovidetheservicelistedand/orifasubcontractingfirmisperformingtheservice.
ServiceProvided EstimatedRevenuesfortheNext12MonthsResidentialDecoratingServices: $
CommercialDecoratingServices: $
ElectricalServices: $
PlumbingServices: $
GeneralContractingServices: $
LandscapeDesignServices: $
*StructuralDesignServices: $
ActualConstruction,Installation,orErection: $**ProductSalesManufacturedbyaThirdParty:
(pleaselisttypesofproductsandrevenuebreakdownbelow)$
________________________________________________________ $
________________________________________________________ $
Other:__________________________________________________ $*NOTE:PleaserequestthesupplementaldesignerapplicationfromPROLINKifyouprovidestructuraldesignservices.
**NOTE:IfyouarepurchasingCGLcoverage andyourproductsalesmakeupmorethan50%ofyourtotalrevenuesthenyouMUSTpurchaseproductsliabilitycoverageunderOptionDonpage3ofthisapplication.
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PROLINKInsuranceGroupInc.|480UniversityAve.Suite800TorontoON.M5G1V2|TF:8006636828|F:4165951649|E:[email protected]
7. Pleasecompletethefollowingtable:
Haveyoueverbeentherecipientofanyallegationsofprofessional❏ YES❏ NOnegligenceeitherinwritingorverbally?
Areyouawareofanyfacts,circumstancesorsituations,which❏ YES❏ NOmayreasonablygiverisetoclaim,otherthanadvisedabove?
8. Pleasecompletethefollowingtable:
DoyoucurrentlycarryanyCommercialGeneralLiabilityorProfessionalLiabilityinsurance?If“YES”pleaseprovidethefollowingdetailsbelow:
CurrentInsurer:
Policy#:
Premium:
E&OLimitsofInsurance:ExpiryDate:
CGLLimitsofInsurance:ExpiryDate:
OfficeContentsLimitsofInsurance:ExpiryDate:
9. Hasanyinsurereverdeclined,cancelledorimposedspecial
conditionsforanycoverageforyouoryourentityinthepast? ❏ YES❏ NOIf“YES”pleasegivedetails:
10. HaveyoureportedanyCommercialGeneralLiabilityorOfficePropertyclaimsinthepast5years? ❏ YES❏ NOIf“YES”pleasegivedetails:
PLEASENOTE: TheminimumretainedpremiumnotedinthechartsbelowindicatetheamountretainedbytheinsurerwhenitisGREATERthan
theearnedpremiumforyourtimeinsuredwithBerkleyInsuranceCompany(intheeventthepolicyiscancelledmid-term).
1. Theproratedpremiumforashort-termpolicy(themasterpolicyexpiresJune1,2017).2. TheearnedpremiumforyourtimeinsuredwithBerkleyInsuranceCompanyintheeventthepolicyiscancelledmid-term.
CDECA Insurance P rogramNewBus iness App l i ca t ion (07 27 16 ) Page3of7
PROLINKInsuranceGroupInc.|480UniversityAve.Suite800TorontoON.M5G1V2|TF:8006636828|F:4165951649|E:[email protected]
SECTION3: COVERAGEFORE&OLIABIL ITY ANDCOMMERCIALGENERALL IABIL ITY INSURANCE
OPTIONA–E&OLIABILITYONLYPLEASENOTE:OptionAisforE&OLiabilityONLY.Pleaseselecttheappropriatepremium:
OptionA–E&OProtectionforservicesprovidedbyuptoTWOaccreditedInteriorDecoratorsorDesignersasrecognizedbyCDECA.
AnnualPremium
MinimumRetainedPremium
Limit:
BasePremium
$500,000limitperclaimand$500,000annualaggregatelimit($0deductible): ❏ $400.00 $100.00
$500,000limitperclaimand$1,000,000annualaggregatelimit($0deductible): ❏ $475.00 $150.00
$1,000,000limitperclaimand$1,000,000annualaggregatelimit($0deductible): ❏ $540.00 $175.00
$2,000,000limitperclaimand$2,000,000annualaggregatelimit($0deductible): ❏ $725.00 $200.00
OPTIONB–ADDITIONALPROFESSIONALSPleaselistalldesignatedprofessionalsworkingforyourfirm:
NameofProfessional: JobPosition:
TheE&OpolicypremiuminOptionAwillprovidecoverageforupto2professionals,INCLUDINGYOURSELF.
Forfirmswith3orMOREprofessionals,youMUSTpurchaseadditionalcoverage.
PleaseselecttheappropriateadditionalpremiumPERadditionalprofessionalemployed.
AIIcoverageoptedformustsharethesamelimitofliabilityasthatchoseninOptionAabove.
Pleaseselecttheappropriatepremium:
OptionB–AdditionalProfessionalsAnnual
PremiumMinimum
RetainedPremium
Limit:BasePremiumPerProfessional
$500,000limitperclaimand$500,000annualaggregatelimit($0deductible): ❏ $75.00 $25.00
$500,000limitperclaimand$1,000,000annualaggregatelimit($0deductible): ❏ $85.00 $35.00
$1,000,000limitperclaimand$1,000,000annualaggregatelimit($0deductible): ❏ $95.00 $45.00
$2,000,000limitperclaimand$2,000,000annualaggregatelimit($0deductible): ❏ $130.00 $60.00
CDECA Insurance P rogramNewBus iness App l i ca t ion (07 27 16 ) Page4of7
PROLINKInsuranceGroupInc.|480UniversityAve.Suite800TorontoON.M5G1V2|TF:8006636828|F:4165951649|E:[email protected]
OPTIONC–ADDITIONOFCOMMERCIALGENERALLIABILITY(CGL)
CommercialGeneralLiability(CGL)canprotectyouagainstclaimsbroughtagainstyouforbodilyinjuryorpropertydamagesustainedbyathirdparty(i.e.,yourcustomers).
Pleaseselecttheappropriatepremiumrequired:
OptionC–CGL AnnualPremium
MinimumRetainedPremium
Limit: BasePremium
$1,000,000limitperoccurrenceand$1,000,000annualaggregatelimit:($1,000deductible) ❏ $250.00 $75.00
$2,000,000limitperoccurrenceand$2,000,000annualaggregatelimit:($1,000deductible)
❏ $325.00 $100.00
$3,000,000limitperoccurrenceand$3,000,000annualaggregatelimit:($1,000deductible) ❏ $425.00 $125.00
$5,000,000limitperoccurrenceand$5,000,000annualaggregatelimit:($1,000deductible)
❏ $700.00 $200.00
OPTIOND–PRODUCTSALESLIABILITYCOVERAGE
IfyouarepurchasingCGLcoverageandyourproductsalesmakeupmorethan50%ofyourtotalrevenuesthenyouMUSTpurchaseproductsliabilitycoverage.PleasenoteifyouelectthiscoveragethelimitselectedMUSTmatchthatoftheCGLlimitselectedabove.ThiscoveragecanonlybepurchasedwiththeCGLpolicy.
Pleaseselecttheappropriatepremiumrequired:
OptionD–ProductSalesLiabilityCoverageAnnualPremium
MinimumRetainedPremium
Limit: BasePremium
$1,000,000limitperoccurrenceand$1,000,000annualaggregatelimit:($1,000deductible) ❏ $200.00 $50.00
$2,000,000limitperoccurrenceand$2,000,000annualaggregatelimit:($1,000deductible)
❏ $250.00 $75.00
$3,000,000limitperoccurrenceand$3,000,000annualaggregatelimit:($1,000deductible) ❏ $325.00 $100.00
$5,000,000limitperoccurrenceand$5,000,000annualaggregatelimit:($1,000deductible)
❏ $550.00 $175.00
CDECA Insurance P rogramNewBus iness App l i ca t ion (07 27 16 ) Page5of7
PROLINKInsuranceGroupInc.|480UniversityAve.Suite800TorontoON.M5G1V2|TF:8006636828|F:4165951649|E:[email protected]
SECTION4: PROPERTYANDCRIME INSURANCE
OPTIONE-OFFICEPACKAGE-PROPERTYANDCRIMEINSURANCE
PleasenoteyouMUSThaveCGLinsuranceinplaceinordertobeeligibleforthiscoverage.
OptionE-OfficePackageAnnualPremium
MinimumRetainedPremium
$30,000BusinessContents(includingExteriorSignsandElectronicDataProcessingEquipmentandMedia)*excludeslaptops ❏ $400 $50
*Higherlimitsavailableforadditionalpremium ❏ Iwouldlikeaquoteforhigherlimits
PLEASENOTE: Ifthisisyourfirsttimepurchasingthiscoverage,asupplementalapplicationwillneedtobecompleted. [email protected].
Ifyouarerenewingyourofficepackage,pleaseanswerthequestionsbelow:
1. Havetherebeenanychangestoyourlocation? ❏ YES❏ NO
2. Havetherebeenanychangestoyouroperations? ❏ YES❏ NO
3. Doyourequireanychangestothecurrentlimitsofinsuranceyoucarry? ❏ YES❏ NO
Ifyouhaveanswered“YES”toanyoftheabovequestions,ORifyourequireaquoteforhigherlimitsthanlistedintheabove
chart,asupplementalapplicationwillneedtobecompleted.PleasecontactCDECA@LMS.CAtoobtainacopyofthisdocument.
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PROLINKInsuranceGroupInc.|480UniversityAve.Suite800TorontoON.M5G1V2|TF:8006636828|F:4165951649|E:[email protected]
SECTION5: PREMIUMSUMMARY SECTION3 - COVERAGEFORL IABIL ITY INSURANCE
OptionA–Errors&OmissionsInsurance: $
+
OptionB–AdditionalProfessionals(ifselected): $
+
OptionC–CGLCoverage(ifselected): $
+
OptionD–ProductSalesLiability(ifselected): $
SUBTOTAL:
PST(8%forOntarioResidents)orRST(8%forManitobaResidents/15%forNewfoundlandResidents)or
QST(9%forQuebecResidents):
SECTION3TOTAL: $
SECTION4 – PROPERTY INSURANCE
OptionE–OfficePackage(ifselected): $
SUBTOTAL: $
PST(8%forOntarioResidents)orRST(8%forManitobaResidents/15%forNewfoundlandResidents)or
QST(9%forQuebecResidents):$
SECTION4TOTAL: $
SECTION3+SECTION4TOTAL:
PROGRAMADMINISTRATIONFEE: $15.00
GRANDTOTAL(SECTION3&4TOTAL+PROGRAMADMIN.FEE): $
ADDITIONALFEES: Pleasenotea$35feewillbeassessedforanytransactiondeclinedduetonon-sufficientfunds.
CDECA Insurance P rogramNewBus iness App l i ca t ion (07 27 16 ) Page7of7
PROLINKInsuranceGroupInc.|480UniversityAve.Suite800TorontoON.M5G1V2|TF:8006636828|F:4165951649|E:[email protected]
IMPORTANTNOTICETOAPPLICANT:
Thisisanapplicationforinsuranceandtheinsurerisnotobligatedtoaccepttheapplicantforcoverage.Ifapolicyisissued,onesignedcopyoftheapplicationwillbe attached to the policy or certificate. Signature on the application form and submission of a premiumpayment does not bind the insurer to complete aninsurance transactionwith the applicant. This policy provides Errors andOmissions insurance that applies on a claims-made basis. The following provides ageneraldescriptionofthiscoverageandissubjecttothetermsandprovisionsoftheactualpolicy.
A. ThepolicywillnotcoveranylossesfromincidentswhichtakeplacebeforetheRetroactiveDate,ifany,oraftertheexpirationofthepolicyperiod(subjecttotheExtendedReportingPeriodprovision).
B. ThepolicywillprovidecoverageforlossesfromincidentswhichtakeplaceonoraftertheRetroactiveDate,ifany,butbeforethebeginningofthepolicyperiodonlyiftheinsureddidnotknowoftheincidentbeforethebeginningofthepolicyperiod.
C. Thepolicywillnotcoveranylossforwhichaclaimisfirstmadeafter:
1. Theexpirationofthepolicyperiodoritsearlierterminationdate,ifany;or
2. TheExtendedReportingPeriodifanyandthenonlyinaccordancewiththetermsdescribedinthepolicy.
D. Thepolicywillonlycoverclaimswhicharefirstmade:
1. Duringthepolicyperiod;or
2. DuringanExtendedReportingPeriodifanyandthenonlyinaccordancewiththetermsandconditionsdescribedintheExtendedReportingPeriodSectionofthepolicy.
E. PleaserequestacopyofthePolicyandreviewthetermsandconditionstoobtainmoreinformation.
F. ThelimitsforDefenceCostsareoverandabovetheliabilityandwillnotreducethelimitofliability.
DisclosureandConsent:
As part ofmy application for insurance I consent to the collection and use of personal information required for the purposes of consideringmy application forinsurancebytheinsurerandtheauthorizedinsurancebrokerforOntarioApplicants,LMSPROLINKLtd.,and/ortheauthorizedinsurancebrokerforapplicantsoutsideofOntario,ThePROLINKInsuranceGroupInc.Theinsurerandthebrokerareauthorizedtocollect,use,anddisclosepersonalinformationandprovidesuchpersonalinformationtothirdparties,asrequiredforthepurposeofunderwritingthisapplicationfor insurance,aspermittedbytherelevantprovincialandfederalprivacylawsorotherapplicablelaws,andasrequiredbytheapplicant’sassociationand/orgoverningbody.IunderstandthatatanytimeImayasktoreviewthepersonalinformationpertainingtomyapplicationforinsuranceandtheinsurerandbrokerwillbeobligatedtoprovidemewithanyinformationIamentitledtoreceiveunderthe relevant provincial and federal privacy laws or other applicable laws. I have reviewed the information in this Application, gathered information from allpartners/directors/officers/employees/agentsunderthisentitywhetherpresentorpriorregardingtheirknowledgeorawarenessofanyclaimsorsituationswhichmaygiverisetoanyclaimsTheClaimInformationForms,ifany,thatareattachedtothisApplicationincludethedetailsof:
A. Allfacts,situations,andincidentswhichhaveoccurredinthepastandwhichmayreasonablybeexpectedtoresultinaclaim,suitorarbitrationagainstus(theApplicant);
B. Allfacts,situations,andincidentswhichhaveoccurredinthepastandwhichmayreasonablybeexpectedtoresultinaclaim,suitorarbitrationagainstus(theapplicant) inthefuture.Allsuchclaims,suitsandincidentshavebeenreportedtoour(Applicants)currentorprior insurer(s). It isunderstoodandagreedthatallsuchclaims,suits,arbitrations,factsituationsandincidentswillbeexcludedfromcoverageunderanypolicyissuedbytheinsurer.
Itisunderstoodandagreedthatfailuretoprovidetrueandcompleteresponsetoanyofthequestions,statementsorrequestforinformationinthisApplicationortoprovideanyotherinformationmaterialtothisApplicationmay,atthesoleoptionoftheinsurer,resultinthevoidingoftheinsurancepolicyissuedinrelianceonthisApplicationand/ordenialofcoverageforspecificclaimsassertedagainstus(theApplicant)oranyotherinsuredunderthepolicy.TheundersignedonbehalfoftheApplicantandallotherinsuredsunderthispolicyissuedbytheinsurer,herebywaivesanydefensetoanactionbytheinsurerforvoidingorrevokingofthepolicybaseduponmisrepresentationoffactorfailuretodisclosematerialinformationinconnectionwiththisApplication.TheApplicantagreestoholdtheinsurerharmlessfrom all loss as a result of any suchmisrepresentation or failure to disclose, including,without limitation, all costs and attorney fees incurred by the insurer inconnectionwithsaidactionforvoidingorrevokingthepolicy.IHEREBYDECLAREthattheabovestatementsandparticularsaretruetothebestofmyknowledge,thatIhavenotsuppressedormisstatedanyfactsandIagreethatthis application shall form part of the insurance policy. I also acknowledge that I am obligated to report any changes that could affect the disclosures in thisapplicationthatoccurafterthedateofsignature,butpriortotheeffectivedateofcoverage.
Applicant’sSignature:______________________Name(pleaseprint):______________________Date:_______________
PLEASECOMPLETEANDRETURNTHEAPPLICATIONTHROUGHONEOFTHEFOLLOWINGMETHODS:
ü V ia EMAIL p lease send to : [email protected]
ü V ia FAX p lease send to : 416 595 1649 a t tn . CDECA PROGRAMMANAGER
ü V ia MAIL p lease send to : PROL INK Insurance Group Inc . 480 Un ivers i ty Ave . Su i te 800 Toronto , ON.M5G1V2
