APPLICATION FOR UMBRELLA & EXCESS LIABILITY INSURANCE

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1 APPLICATION FOR UMBRELLA & EXCESS LIABILITY INSURANCE For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Liberty Mutual Insurance Company s insurance business in Canada. GENERAL INFORMATION: Named Insured: Mailing Address: New Renewal Policy Period: Limit Requested: Producer Name: Canadian Sales: U.S. Sales: Rest of World Sales: (List Countries) 1 8

2 Insured is: Corporation Partnership Joint Venture Other: Years in Business: Canadian Payroll: U.S. Payroll: Has applicant operated under a different name? Payroll: Rest of World (List Countries) If yes, please list names: OPERATIONS OF INSURED: List all subsidiaries (attach a separate listing if necessary): Name Location Operations Sales/Payroll/Number of Employees 2 8

3 Is this application to cover all operations/subsidiaries? If not, please explain in Remarks Section Note: If real estate operations are indicated, a complete listing of all locations (inc. occupancy, number of stories, square footage) should be attached. PRODUCTS LIABILITY: If not fully outlined in the Operations of Insured section, describe products manufactured, sold, handled or distributed. Please attach sales brochures, the latest annual report or other descriptive material (if available): Do you have a formal products recall plan in place? Do you have record keeping and document retention procedures in place? Are there documented product safety and loss prevention/control programs in effect Do you comply with all labeling requirements in each jurisdiction where your products are sold? Yes No Note: If you answer Yes to any of the following questions, please explain in the Remarks Section Have any products been discontinued or recalled during the last 5 years? Are any products used or installed in any aircraft, spacecraft or missiles? Are any products used or installed in any nuclear installations or ocean-going vessels? Do you sell, distribute or handle any herbal, dietary or pharmaceutical products? Are you planning on introducing any new products within the next 12 months? Do sales representatives, employees or agents give advice to end-users of products sold? COMPLETED OPERATIONS LIABILITY: Do you perform contracting/construction operations? If yes, please complete this section and attach a schedule of ongoing and planned work/projects, along with a description of your 5 largest jobs in the last 3 years: What percentage of the work do you subcontract to others? % What type of work is subcontracted? What limit of liability insurance do you require your sub-contractors to carry? $ Are all sub-contractors required to provide certificates of insurance? 3 8

4 Do you require that your subcontractors hold you harmless? Do you require subcontractors to include you as an additional insured on their insurance? Do you employ architects and/or engineers? If you answered Yes to the question above, is any design work for others performed? 4 8

5 Is there any work performed on bridges or tunnels? Is any hazardous material handled? Do you lease equipment to others? Do your operations involve any blasting, pile driving, underpinning, weakening of supports, demolition or caisson work? CONTRACTUAL LIABILITY: Do your contracts with suppliers and independent contractors contain hold harmless agreements in your favor? Do you require certificates of insurance from suppliers and independent contractors? If you answered Yes to the question above, what limits of insurance are suppliers and independent contractors required to carry? $ What percentage of sales are derived from the work or services of independent contractors? % AUTOMOBILE LIABILITY: Radius (Km) Type No. Canadian No. U.S Private Passenger: Light Truck: Medium Truck: Heavy Truck: Tractor: Trailers: Buses: Other: What property do you transport? Are explosives, caustics, flammable or other hazardous cargo hauled? Are any units involved in backhauling goods of others? If yes, please provide details concerning the frequency and route of such trips. Please also comment on the number of third parties and types of goods involved: Is coverage provided for all autos, including hired car/non-owned? Are passengers carried for a fee? Are any units registered in Ohio? AIRCRAFT AND WATERCRAFT LIABILITY: 5 8

6 List and describe any owned, non-owned, leased or chartered aircraft. Please include the type of aircraft, number of seats, hours used and purpose of use: Does the applicant own or maintain a landing strip or aircraft hangar? Are any non-owned aircraft chartered without crew? List and describe any owned, non-owned, leased or chartered watercraft. Please include the type, length, horsepower, number of seats, hours used and purpose of use: Does the applicant own or maintain a waterfront facility/operation? EMPLOYERS LIABILITY: Are all employees covered by Worker s Compensation Insurance? If not, give details, including number of such employees: Is Employer s Liability Insurance carried on employees not covered by Worker s Comp.? POLLUTION LIABILITY: Do you generate, store, treat or dispose of hazardous waste or caustic chemicals? If Yes, please describe: During the last five (5) years, have you had any reportable releases or spills of hazardous substances, hazardous waste or any other pollutants, as defined by applicable environmental statutes or regulations? If Yes, please describe in detail: Indicate the nature of the Pollution Exclusion on the underlying policies: Are there any underground storage tanks (USTs) over 10 years old? 6 8

7 CARE, CUSTODY OR CONTROL: A) List all leased real properties with values in excess of C$ 1,000,000: Location Occupancy: Estimated Value B) List all other properties in care, custody or control with values in excess of C$ 25,000. Include property such as EDP equipment, leased equipment, leased machinery, aircraft or watercraft, material on consignment, property stores or in transit, and exposures under installation and other floater policies, etc: Location Description Estimated Value C) Is any of the property listed in A) and B) above excluded by any policy listed in the Schedule of Underlying Insurance? OTHER LIABILITY: Note: If you answer Yes to any of the following questions, please explain in the Remarks Section Do you provide any consulting or inspection services to others for a fee? Do you operate a hospital, clinic or first aid facility? Are any doctors or nurses employed by your business? Do you own, maintain or operate any railroads? Are there advertising expenditures in excess of $50,000 annually? Is any advertising agency used? If you answered Yes to the question above, are you listed as an Additional Insured by the advertising agency s insurance policy? 7 8

8 LOSS EXPERIENCE: For each line of insurance, give aggregate loss experience (number of claims and total dollar value) for the past five (5) years including expenses and outstanding reserves (primary carriers computer loss runs may be substituted): Auto Liability General Liability Products Liability Year # of Losses - $ Amount # of Losses-$ Amount # of Losses-$ Amount For each incurred claim in excess of C$50,000, please describe (Attach sheet with further details if necessary): Date of Occurrence Incurred Value (Payments, Expenses & Reserves) Description of Claim Are you aware of any situation that may give rise to a claim? If yes, please explain: PREVIOUS COVERAGE HISTORY: Who is the current carrier? What limit of liability is carried: Premium: Has any umbrella coverage been cancelled or non-renewed within the last three 5 years? 8 8

9 SCHEDULE OF UNDERLYING INSURANCE: Policy Type Carrier Products/Completed Operations Aggregate Commercial General Liability Employer s Liability Automobile Owned Aircraft Non-Owned Aircraft Watercraft: Non- Owned Employee Benefits Other Other Other General Aggregate Policy Period Annual Premium REMARKS Please use this section to provide any other pertinent information 9 8

10 THIS IS NOT A BINDER OF COVERAGE IT IS AGREED HOWEVER, THAT THIS APPLICATION SHALL FORM THE BASIS OF THE CONTRACT, SHOULD THIS POLICY BE ISSUED BY THE COMPANY. IT IS WARRANTED THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSRUANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. Name and Title of Applicant Signature of Applicant Date BROKER ACKNOWLEDGMENT THE UNDERSIGNED ACKNOWLEDGES THAT ANY PERSONAL INFORMATION CONTAINED IN THIS APPLICATION HAS BEEN COLLECTED IN ACCORDANCE WITH ALL APPLICABLE PRIVACY LEGISLATION. THE UNDERSIGNED CONFIRMS THAT IT HAS OBTAINED THE NECESSARY CONSENTS TO THE COLLECTION, USE, AND DISCLOSURE OF SUCH INFORMATION FOR THE PURPOSES OF ASSESSING THE APPLICATION FOR INSURANCE, INVESTIGATING AND SETTLING CLAIMS, DETECTING AND PREVENTING FRAUD, AND ACTING AS REQUIRED OR AUTHORIZED BY LAW. WHEN YOU COLLECT PERSONAL INFORMATION, YOU MUST EXPLAIN THE PURPOSE FOR THE COLLECTION AND ANY USE AND DISCLOSURE OF THE PERSONAL INFORMATION. YOU MUST ALSO ENSURE THAT YOU HAVE OBTAINED THE INDIVIDUAL S INFORMED CONSENT TO PROVIDING SUCH INFORMATION TO US FOR THESE PURPOSES. Name of Broker Signature of Broker Date 1 8

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