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To the Policyholder The Boiler Inspection and Insurance Company of Canada (BI&I)

Jurisdictional Inspection Requirement Form for Boilers and Pressure Vessels The Technical Standards and Safety Authority (T.S.S.A.) will be introducing new regulations for boilers and pressure vessels, July 1, 2018.

Ontario law requires routine jurisdictional inspections of boilers and pressure vessels to ensure they’re in safe working order.

If your policy includes equipment breakdown coverage for boilers and pressure vessels, we will continue to complete the required inspections and file a Record of Inspection with T.S.S.A. on your behalf for no additional charge.

Effective July 1, 2018, you will be required to obtain the Certificate of Inspection from T.S.S.A for a fee. For more information, visit TSSA’s website.

Purpose of this form To help ensure all applicable equipment receives jurisdictional inspections, please complete the information on the following pages if you have any of the listed equipment on your premises and you are:

A new client, or

An existing client & have not advised us previously of any of the items below, or

An existing client with changes to your premises that involve any of the items below.

Once completed, please return this form:

By fax to (416) 362-6601

Scanned and emailed to safety@biico.com

Submit form electronically as shown on page 3

What happens after I have completed and sent in this form? You will be contacted by The Boiler Inspection and Insurance Company of Canada (BI&I) to arrange an inspection if your equipment requires it. If you need assistance in the meantime, please contact your insurance broker.

Thank you,

The Boiler Inspection and Insurance Company of Canada (BI&I)

© 2018 The Boiler Inspection and Insurance Company of Canada (BI&I). All rights reserved. 2/3

The Boiler Inspection and Insurance Company of Canada (BI&I)

Jurisdictional Inspection Requirements Form for Boilers and Pressure Vessels

Policy holder’s name:

Policy number:

Policy effective date:

Policy expiration date:

Information about your equipment The boilers and pressure vessels listed below fall under the Ontario jurisdictional inspection requirements. Please indicate if you have any of the following equipment on your premises.

Please check all that apply and advise quantities:

Applies Qty. Equipment

High Pressure Boilers

Steam over 15psi [pounds per square inch], water over 160psi & 250oF

Low Pressure Boilers Steel boilers, cast iron boilers, steam at 15psi or less, hot water heating & supply (water at

160psi or less and not over 250oF) having a heating surface over 30 ft.2

Oil Heat Transfer Boilers Whether vented or under 15psi, or over 15psi

Unfired Pressure Vessels

Over 6” diameter and over 1.5 ft.3 and over 15psi, quick opening doors (e.g.autoclaves), and hospital sterilizers

Cushion Tanks (over 24” diameter)

Hydro-Pneumatic Tanks (over 24” diameter)

Hot Water Storage Tanks (over 24” diameter)

Air Receivers (over 250psi or 23 ft.3)

Ammonia Refrigeration System

Deaerators

Other (please specify):

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The Boiler Inspection and Insurance Company of Canada (BI&I)

Your Contact Information (Please fill in all fields)

Inspection Contact

Inspection Contact Name:

Inspection Contact Email:

Phone Number:

Billing Contact (Required by T.S.S.A), if different from Inspection Contact

Billing Contact Name:

Billing Contact Email:

Phone Number:

Locations

Address of equipment location(s) and expiry date of current Certificate of Inspection: (Please include street address, city, province and postal code) Location:

Certificate expiry date: Location:

Certificate expiry date: Location:

Certificate expiry date:

Please return completed form

By fax to (416) 362-6601 or,

Scanned and emailed to safety@biico.com or,

Submit form electronically by clicking the button below

Thank you again for choosing The Boiler Inspection and Insurance Company of Canada for your insurance needs. We are pleased to provide this service to you.