RealProSure Insurance Program Application

Transcription

1 Section Client Information. Name of Brokerage (Must included the full legal name and operating name): Legal Name: Date Established: Operating Name:. Previous Business Name: Date Dissolved:. Do you operate outside of Canada? Yes No 4. Brokerage Insurance Contact Name: Phone Number: 5. /Website address for insurance contact and broker owner: Contact: Broker Owner: Website Address: 6. Postal address of the brokerage: Address: City: Province: Postal Code: 7. Do you require Commercial General Liability Insurance? Yes No (If Yes, please complete Section below) (If No, please complete section, for Professional Error and Omissions Insurance or Property Insurance) Section - Commercial General Liability Insurance ($5 Million Limit of Insurance) 8. Have you ever been declined for insurance or had your policy cancelled? Yes No 9. Provide details of all Commercial General Liability (CGL) and Professional Error and Omissions (PE&O) Insurance carried during the past years: Type of Policy (PE&O or CGL) Policy Number Company Expiry Date Limits 0. Have you had any claims in the last 5 years? Date Type of Loss Amount Paid Amount Outstanding. Number of licensed associates participating in operations:. Will you be making Commercial General Liability Insurance mandatory for all Associates within your Brokerage? Yes No (If you answered No, we will provide you with a form for associates to sign, waiving insurance coverage). Page of 6

2 . Please list all the Licensed Associates at Brokerage that require coverage: # of Licensed Associates Names Property Management Type of License Held (Please check off ALL that apply) Real Estate Mortgage Broker Business Broker Real Property Market Value Appraisals 4. Total Brokerage Gross Revenues less Commissions: DESCRIPTION OF ACTIVITIES Gross Revenues Less Commissions EARNED DURING LAST MONTHS ESTIMATED FOR NEXT MONTHS Real Estate Sales (Gross Revenues less Commissions) Please indicate gross commission percentages in each of the following categories: Commercial % % Residential % % Industrial % % Rural (including Farms and Resorts) % % Market Value Appraisals (on a fee basis) Real Estate Consulting with no Real Estate Transaction Component Property Management (excluding Strata Corporations) Property Management of Commercial and Residential Strata Corporations Mortgage Brokering Real Property Leasing Business Brokering Other TOTAL Years In Business for Operation Number of Associates in the Operation Page of 6

3 5. Are there any drones being used? (By the brokerage, licensed associates, employees, etc ) Yes No 6. Would you like a quote on Cyber Liability Coverage? Yes No *** All Applicants must complete the next section () Section Insurance History 7. Has any person in your organization ever been the object of a dismissal, suspension, or disciplinary sanction? 8. After making an inquiry of all members of the Applicant Firm, including predecessors in business and former staff, either individually or otherwise, has anyone, in the past five years, ever been the subject of a claim in respect of the liabilities to be covered by the proposed insurance? 9. After making an inquiry of all members of the Applicant Firm, including predecessors in business and former staff, either individually or otherwise, has anyone, in the past five years, ever given notice of a possible claim to an Insurer in respect of the liabilities to be covered by the proposed insurance? 0. After making an inquiry of all members of the Applicant Firm, including predecessors in business and former staff, either individually or otherwise, is anyone aware of any act or circumstance which could reasonably be expected to be the basis of a future claim in respect of the liabilities to be covered by the proposed insurance?. Declaration: I/WE declare that during the last five years no insurer has cancelled, declined or refused to issue me/us any form of liability insurance and that this application discloses the hazards known to exist at the date of this application. Yes No I/WE declare that the statements made herein are in every respect true and correct and hereby apply for a contract of insurance to be based upon the truth of the said statements. Yes No. Does your brokerage operations include property Management? Yes No (If your brokerage operations include Property Management Operations, please complete Section 4 below) (If your brokerage does not participate in Property Management Operations, please skip to Section 5 below) Section 4 Property Management and Professional Errors and Omissions Supplement. Number of licensed associates participating in Property Management operations: 4. What are the Property Management duties and responsibilities? Page of 6

4 5. How many properties are being looked after? RealProSure Insurance Program 6. What types of properties are they? 7. What exposures are there? (Examples: Pools, Saunas, Elevators, Playgrounds, Gyms) 8. Do you maintain complete records of all incidents occurring at the premises you manage? Yes No 9. Do you sublet any work to independent contractors? Yes No 0. Describe all contracts or agreements assuming Liability of others (ie. Snow Removal), and if you sublet any work to independent contractors, please describe the type of work (ie. Landscaping), and the annual cost of work. Type of Work Annual Cost of Work. Does the applicant enter into formal contractual agreements with independent contractors? Yes No (If yes, do these agreements contain a hold harmless provision in the applicant s favor?) Yes No. Are independent contractors who perform work on behalf of the applicant required to carry Commercial General Liability insurance including products/completed operations coverage? Yes No. Do you request Certificates or proof of insurance from independent contractors before they begin working? Yes No 4. What limit of Liability do you require Independent contractors to carry? 5. Does the applicant provide professional services for any firm or company in which the applicant has an ownership interest? Yes No (If YES, please append the full details and show the percentage of gross revenues derived there from.) Details % of Gross Revenues 6. Please indicate what limit of insurance you would like quoted? $ Million $ Million 7. DISCLOSURE, AUTHORIZATION AND SIGNATURE: I/We hereby declare for and on behalf of the Applicant Firm and each and every one of its members to be insured, that to the best of my/our knowledge, the above statements and particulars in this application are true and complete and that I/we have not omitted, suppressed or misstated any material facts. I/we agree that this application, together with any other information supplied by me/us shall form the basis of any Contract of Insurance effected there from. I/We undertake to inform Insurers of any material alteration to these facts whether occurring before or after completion of the Contract of Insurance. Furthermore, I/we understand and accept that this insurance applied for provides coverage on a "claims made and reported" basis and that coverage under the policy, if issued, shall not apply to any known claim or circumstance that could reasonably give rise to a future claim that is known to myself, the Applicant Firm or its members prior to the inception date of the policy nor to any claim or circumstance reported after the expiration, cancellation or termination of the policy. I/We also give authorization to Intact Insurance Company, its affiliates, agents and representatives to verify, obtain and exchange any information in connection with the insurance applied for in this application. This consent is valid with respect to any policy extension and/or renewal of coverage with Intact Insurance Company, or any of its affiliates. Page 4 of 6

5 SIGNING THIS APPLICATION DOES NOT BIND THE APPLICANT FIRM NOR THE INSURER TO COMPLETE THE INSURANCE APPLIED FOR HEREIN. Signature of individual Applicant or Duly Authorized Officer: Title: Date of : IMPORTANT: This type of insurance coverage applies only to claims made and reported to the Insurer during the policy period. Coverage does not apply, however, to claims that arise out of errors, omissions or negligent acts or facts or circumstances that may reasonably give rise to a claim at a future date that are known to the applicant at the time when this application is signed and dated. Therefore, if the applicant is currently insured by an Insurer other than Intact Insurance Company and/or its affiliated companies, and that contract of insurance is on a claims made basis, it is incumbent upon the applicant to report all known circumstances which may give rise to an eventual claim to that Insurer. Please refer to your Insurance Broker if you do not understand the foregoing. *** All applicants must complete the next section 4.5. Section Would you like a quote on Property Insurance? Yes No (If you select Yes, please complete Section 5 below) (If you select No, submit your completed application form to a member of the RealProSure team for a quotation) Adam Thomson Caitlin Bida athomson@toolepeet.com cbida@toolepeet.com Section 5 Property Insurance Supplement 9. Please enter the risk address, year built, # of stories, and square footage of each location you would like to insure. Please also note if the location has a basement, the box must be checked or type Yes. (Please note if you have more than one property, you must list them all under each category and answer the applicable question regarding the details of the risk for all sections). # Risk Address (Must include postal code) Year Built # of Stories Basement (Yes or No) Page 5 of 6 Square Footage Occupied 40. Please enter the number of KM s from the nearest Fire Hall and the number of KM s from the nearest Fire Hydrant for each location you would like to insure. Please also note if the location has a Fire Alarm and Burglar Alarm, the box must be checked or type Yes. Risk # s Continued as entered above # KM from Fire Hall # KM from Fire Hydrant Fire Alarm (Yes or No) Burglar Alarm (Yes or No) 4. Please enter the type of Wall and Floor Construction type of all locations, you may enter any of the following options: Risk # s Continued as entered above Wall Construction ) Reinforced Concrete ) HCB, Brick, Masonry ) Brick Veneer 4) Metal Clad - Steel Frame 5) Metal Clad Wood Frame 6) Frame Floor Construction ) Reinforced Concrete ) Concrete Pad ) Wood

6 (If you own a building(s), please complete Question # 4, if you rent/lease a space(s), please complete Question #4). 4. Please enter the amounts of Insurance (Replacement Value) of your building and property in the chart below. Risk # s Continued as entered above Building Limit Office Equipment and Contents Limit Tenant Improvements Limit Other Property Limit (Please indicate what the item is) 4. Please enter the amounts of Insurance (Replacement Value) of your property in the chart below. Risk # s Continued as entered above Office Equipment and Contents Limit Tenant Improvements Limit Other Property Limit (Please indicate what the item is) Other Property Limit (Please indicate what the item is) 44. Do you have any specific lease agreements we should be aware of, such as a photo copier or telephone system equipment, etc? Or do you require any third party interests be named as Additional Insured? (If you do, please submit your lease agreements with the application. We will require your lease number(s), contract number(s), description of the item(s), value(s), and serial number(s), as well as the location the items are at). 45. Is there a financial interest on the property/location(s)? (If yes, please indicate the full name and address of the financial interest(s)). Location # Name Address City Province Postal Code Additional Property Coverage s 46. Would you like a quote on Sewer Back-Up Coverage? Yes No 47. Would you like a quote on Flood coverage? Yes No 48. Would you like a quote on Actual Loss Sustained Business Interruption Coverage? Yes No 49. Would you like a quote on Boiler and Machinery Coverage? Yes No Page 6 of 6