Download - INSURANCE APPLICATION FOR THE CANADIAN …...(including Exterior Signs and Electronic Data Processing Equipment and Media) * excludes laptops $400 $50 *Higher limits available for

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.



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.



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


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





OPTIONC–ADDITIONOFCOMMERCIALGENERALLIABILITY(CGL)

CommercialGeneralLiability(CGL)canprotectyouagainstclaimsbroughtagainstyouforbodilyinjuryorpropertydamagesustainedbyathirdparty(i.e.,yourcustomers).

Pleaseselecttheappropriatepremiumrequired:

OptionC–CGL AnnualPremium


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



❏ $700.00 $200.00

OPTIOND–PRODUCTSALESLIABILITYCOVERAGE

IfyouarepurchasingCGLcoverageandyourproductsalesmakeupmorethan50%ofyourtotalrevenuesthenyouMUSTpurchaseproductsliabilitycoverage.PleasenoteifyouelectthiscoveragethelimitselectedMUSTmatchthatoftheCGLlimitselectedabove.ThiscoveragecanonlybepurchasedwiththeCGLpolicy.

Pleaseselecttheappropriatepremiumrequired:

OptionD–ProductSalesLiabilityCoverageAnnualPremium


Limit: BasePremium



❏ $250.00 $75.00



❏ $550.00 $175.00



SECTION4: PROPERTYANDCRIME INSURANCE

OPTIONE-OFFICEPACKAGE-PROPERTYANDCRIMEINSURANCE

PleasenoteyouMUSThaveCGLinsuranceinplaceinordertobeeligibleforthiscoverage.

OptionE-OfficePackageAnnualPremium


$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.



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.



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