Application Commercial General Liability

THE APPLICANT

Name of Applicant:

Address of Applicant:

A Corporation

A Partnership

An Individual

Other:

Description of operations:

Years of experience:

Year of incorporation/or in business:

Name and address of subsidiaries:

LIMIT OF LIABILITY REQUIRED: $ ,000,000 CGL

Effective date of insurance:

Name of present insurer:

Has any insurer ever refused or cancelled any insurance?	YES	NO

LEASED PROPERTY

Describe all buildings:

LOCATION	AREA	OCCUPANCY	ANNUAL RENT	CONSTRUCTION

Does the Applicant have any interest as owner, lessee or tenant in the following?:

Freight and/or passenger elevator:	YES	NO

If yes, specify number, type, capacity, use and location(s):

Lots:	YES	NO

If yes, specify location, area, use:

Owned watercraft:	YES	NO

OR

Leased or chartered watercraft:	YES	NO

If yes, specify number, type, length, HP:

Leased aircraft:	YES	NO

If yes, specify the number and annual cost of leasing:

OPERATIONS

Description of Applicant’s operations and annual sales:

OPERATIONS PRODUCTS	GROSS ANNUAL RECEIPTS	% DISTRIBUTION
Canada	USA	Other	Total
TOTAL

Number of employees and annual payroll:

ADMINISTRATION	SERVICE	SALES	OTHER	TOTAL
Employees
Annual Payroll

Does the Applicant handle any material that could cause pollution?

YES	NO

INCIDENTAL MALPRACTICE LIABILITY

Does Applicant operate a hospital, a clinic or first aid facility?:

YES	NO

If yes, specify:

Full Time	Part Time
Number of doctors
Number of nurses

Is individual liability of employed doctors and nurses covered by insurance?:

YES	NO

If yes, what are the limits of insurance provided?:

CONTRACTUAL LIABILITY

Does the Applicant assume any liability, by contract, verbal or written agreement?:

YES	NO

If yes, attach wording of such contract or written agreements?:

PRODUCTS LIABILIITY

List by category, all products manufactured, sold, handled, or distributed by the Applicant:

PRODUCT	ANNUAL RECEIPTS

Specify the percentage of annual sales:

In Canada	%
In the USA	%
Other Countries	% List the countries:

Give details of operations away from Applicant’s premises:

Describe products whose manufacturing has ceased.

Give reasons for discontinuing production and year:

Specify annual sales:

Does Applicant have operations outside Canada?:

YES	NO

If yes, in which country and what is the corresponding amount?:

Has the Applicant included brochures or other relevant documentation concerning the products?:

YES	NO

Are there any products or activities related to nuclear energy or defense?:

YES	NO

Do any products or activities imply usage of radio-isotopes or radioactivity?:

YES	NO

OTHER EXPOSURES

Is the Applicant subject to the following risks?:

Work committed to sub-contractors or independent contractors?:

YES	NO

Type of work:

Annual costs:

Railroad operation:

YES	NO

Fully describe any railway network owned, used or operated by the insured:

Advertising:

YES	NO

If yes, description:

Estimated annual advertising expenditure over $10,000:

Advertising agency:

Description of unusual advertising activities such as contests, exhibits:

Pollution (chemical products, gases, wastes):

YES	NO

Specify quantities, methods of storage and handling, methods of transportation off-premises, permission given to others to dispose of waste on premises, type of supervision:

EMPLOYER’S LIABILITY

Is Government Workmen’s Compensation Insurance available in all provinces in which the Applicant conducts business?:

YES	NO

If yes, does Applicant take advantage of it?

YES	NO

If no, specify provinces and payroll:

AUTOMOBILE

Number of vehicles:

Private
Light
Heavy
Motorized Equipment
Trailers
Buses

Number of employees using their car for company business:

Are vehicles used for long haul?:

YES	NO

Across the country?:

YES	NO

If yes, which provinces?:

In the United States?:

YES	NO

If yes, which States?:

If yes, specify:

Products of the Insured:

Products of others:

Are vehicles utilized in the transportation of flammable, caustic or explosive substances?:

YES	NO

Are there any non-owned vehicles/if yes, give details:

YES	NO

Number:

Use:

PREVIOUS LOSS EXPERIENCE

List all liability claims within the last five (5) years, whether settled or not:

BODILY INJURY	PROPERTY DAMAGE	DATE	PAID AMOUNT OR RESERVE

SCHEDULE OF PRIMARY POLICES

COVERAGE	CARRIER	POLICY TERM	LIMIT	PREMIUM
General Liability
Automobile
Professional
Directors and officers
Others (ex. aviation, marine)
Do these policies insure all corporations and subsidiaries list in item 1.? If not, explain:

DECLARATIONS AND SIGNATURE

The Applicant certifies that the above statements and facts are true and that no information has been supressed or misstated.

Date (dd/mm/yyyy)

Signature of Insured

Title

BROKER INFORMATION

Broker:
Contact:
Phone:
Fax: