MONEY LENDING & CHEQUE CASHING APPLICATION

Transcription

1 45 Vogell Road, Suite 306, Richmond Hill, Ontario L4B 3P6 Tel: Toll: Fax: MONEY LENDING & CHEQUE CASHING APPLICATION BROKERAGE: Broker contact: address: Phone.: Fax.: INSURED: Individual Partnership Corporation Joint Venture Full Legal Name: Operating Name: Mailing Address: Risk Location: Principal Owner: Has the principal or any active partner filed for bankruptcy? If yes, provide details: Loss Payee / Mortgagee / Additional Insured (include address below): INSURANCE EXPERIENCE: New Business Renewal Are you incumbent broker? Existing Insurer: Target Premium Required: Renewal Offered: If not, why? Have you had any insurance refused or cancelled within the past 5 years? If yes, please explain: LIST OF ALL LOSSES OR CLAIMS (Whether or not Insured Sustained during Past 5 Years on all operations): Date of Loss Details of Loss Amount Paid/Reserve Open/Closed Describe any insured and uninsured losses which have occurred in the past 5 years and state the date, type and value of each loss before the deductible (if any) was applied: If previous losses/claims have occurred, please advise the steps taken to prevent a re-occurrence? GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 1 of 7

2 Operating Experience: New Venture: If yes, prior experience in this industry: Years in Business: Years of Current Ownership: Years at this Location: List & describe any business owned, operated, or managed by the Insured: Is the Insured a subsidiary of any other identity or does the Insured have any subsidiaries? If yes, please explain: Occupied by Applicant as: Occupied by Other as: Any portion of this building: Vacant or Unoccupied? Under Renovation? If yes, please explain: COVERAGE REQUESTED Section 1 Property Section 3 Commercial General Liability Section 2 Crime Section 4 Boiler SECTION 1 - PROPERTY LOCATION # 1 Year Built: Number of Stories: Total Area: sq ft Area Occupied By Insured : sq ft Occupies Basement? Structure Type: Industrial Plaza Strip Plaza Stand-Alone Building Commercial/Residential Commercial Condo Other: Walls: Frame Brick Veneer Masonry HBC n-combustible Stucco Alum. Siding Fire Resistive Others: Floor: Concrete Wood Joist Wood Others: Roof: Wood Joist Steel Deck Concrete Patent Others: Fire Protection: Fire hydrant within 300 metres/1000 feet Fire Hall within 8km Unprotected Paid Volunteer Distance to Responding Fire Department: Sprinklers: % Smoke Detectors: Heating: Gas Electric Oil Combination Furnace Wood Stove Other: Electrical: Fuses: Circuit Breakers: Updates: Heating: Plumbing: Roof: Electrical : te: Furnace: If more than one building/location, please provide separate schedule. GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 2 of 7

3 SECTION 2 CRIME Number of Employees: Managers Full Time Part Time Are employees bonded? Do Employees undergo police checks? Gross Annual Payroll: How often are Police checks done? Protection: Burglar Alarm: Central Station Monitored Local ne Rated: ULC CSA Full Perimeter Partial Perimeter Contacts : All Windows All Doors Motion Detector Heat Detector Other: CCTV in place Number of Cameras: Procedure involving CCTV? Monitoring Company: Percentage protected: % Dedicated line: Connected for fire detection: Safe: Safe Make: Safe Class: (must be provided) Metal bars on all windows & doors: Are all doors fitted with deadbolts? How Often are bank deposits made? By Whom: *If cash advance operation, separate questionnaire must be completed. SECTION 3 COMMERCIAL GENERAL LIABILITY Sales/Receipts: $ Canadian $ USA $ Other GROSS RECEIPTS DECLARATION: Annual Gross Receipt Cheque Cashing $ $ Money Transfer Service $ $ Sale of Stamps, Tokens or Ticket $ $ Gold & Silver Exchange $ $ Currency Exchange Service $ $ Pay Day Loan Services $ $ Sales of Phone Cards $ $ Mail Box Rentals $ $ Tobacco Related Sales $ $ Other: (Details) $ $ Other: (Details) $ $ Other: (Details) $ $ Total Receipts: $ $ Projected Gross Receipt Are all employees covered by Worker s Compensation? Do you maintain an incident log? Are Certificates of Insurance required? Percentage of work contracted out: % Nature of work subcontracted out: GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 3 of 7

4 Is the coverage required? SECTION 4 BOILER INSURANCE/MECHANICAL BREAKDOWN LIMITS OF INSURANCE Coverage Broad Form Named Perils Deductible Co-Ins Limit of Insurance Building(s) ACV RC 80%/90% $ Contents ACV RC 80%/90% $ Equipment ACV RC 80%/90% $ Stock ACV Only 80%/90% $ Office Equipment 80%/90% $ Electronic Data Processing Equipment 80%/90% $ Profits 100% $ Gross Earnings 80% $ Extra Expense - $ Rents or Rental Value Form 100% $ Sign Form 100% $ 10,000 Glass Rider - $ Blanket Sewer Back-Up $ 10,000 Earthquake 3% or $100,000 $ Included Flood $50,000 $ Included Valuable Papers and Records - $ 10,000 Accounts Receivable - $ 10,000 Newly Acquired or Constructed Buildings $ 1,000,000 Newly Acquired Business Personal Property $ 500,000 Fire Department Service Charges $ 20,000 Peak Season Endorsement $ 25,000 Personal Effects $ 5,000 Property Off Premises $ 10,000 Property In Transit $ 10,000 Damage to Building by Theft $ 5,000 Professional Fees $ 25,000 EDP Equipment, Data and Media $ 25,000 Conviction Reward $ 5,000 Employee Dishonesty - $ Broad Form Money and Securities - $ Loss Inside the Premises - $ Loss Outside the Premises - $ Safe Burglary - $ Money Orders & Counterfeit Paper Currency - $ Included Depositors Forgery - $ Included GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 4 of 7

5 Third Party Computer and Funds Transfer Fraud - $ Included Incoming Cheque Forgery $ Included Credit Card Forgery - $ Included Liability Commercial General Liability Occurrence Form - $ Aggregate Limit Products and Completed Operations $ Medical Payments - $ 10,000 Per Person $ 10,000 Per Occurrence Personal Injury - $ Advertising Injury - $ Tenant s Legal Liability - $ 250,000 n-owned Automobile SPF #6 - $ S.E.F. #99 Excluding Long Term Leased Vehicles Endorsement Boiler Insurance 80%/90% $ Mechanical Breakdown 80%/90% $ BROKER DECLARATION Is this account NEW to your office? If no, how long have you known the applicant? Is the applicant financially sound? Have you personally seen this property? Do you recommend this applicant? Is the property for sale? Comments: I/We hereby declare that the statements and particulars contained in this application are true and that I/we have not suppressed or mis-stated any material facts and I/we agree that should a policy be issued then this application shall be the basis of the contract with Underwriters. This application must be signed by the Producer/Account Executive. Signature of Producer/Account Executive: Date: Print Name of Broker/Producer & Brokerage: GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 5 of 7

6 DISCLAIMER Consumer and previous insurer reports containing personal, credit, factual, or investigate information about the applicant may be sought in connection with this Application for insurance or any renewal, extension, or variation thereof. All provisions contained in the various forms issued under this contract shall be deemed to be contained in the present Application of insurance. The policy may be deemed to be void and claims may be denied where: 1. An applicant for a contract: a) Provides false or erroneous information to the prejudice of the insurer; or b) Knowingly misrepresents or fails to disclose in the Application any fact required to be stated therein; or 2. The insured contravenes a term of the Contract or commits a fraud; or 3. The insured willfully makes a false statement in respect of a claim under the Contract. I CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND ACCURATE AND APPLY FOR A CONTRACT OF INSURANCE BASED UPON THE TRUTH OF THE STATEMENS. I AM IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE CONTRACT BETWEEN THE INVOLVED PARTIES. Signature of Applicant: Date: Title of Applicant: Broker s Signature: Date: GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 6 of 7

7 MONEY LENDING SUPPLEMENT CRITERIA 1. The doors between the secured area tellers room and client service area have deadbolt locks which can only be opened by authorized personnel? 2. The division wall between the secured area and client service area floor to ceiling, either the actual building ceiling or a drop ceiling with the service area counter being constructed of bullet proof glass surrounded by steel framing? 3. Employees are given specific instruction as to their duties in the event of hold-ups and as to the measures to be taken to prevent, control or minimize loss from such incidents? 4. Each teller has a separate cash drawer and separate working fund? 5. Each teller s drawer is reconciled at the end of each shift? 6. There s a ULC certified alarm system, covering the perimeter, and all doors, windows & skylights, and motion detectors covering the secured area and client service area and is it connected and in working order? 7. There s a UL or ULC listed Class 2, TR-15 or better safe located on the premises, and is located within the secured area? 8. There s an inspection of the exterior of the premises for signs of forced entry? 9. Panic Button on Premises? 10. CCTV on Premises? How many Procedure in place: 11. Is there an audit and control procedures manual? 12. Is there an incident report manual on premises? 13. The person responsible for auditing has the authority to check any person and record at any time? 14. A plan exists for the periodic surprise testing of internal control systems under the supervision of the person responsible for auditing, and are all discrepancies reported directly to the owner as soon as practical? 15. A hired guard/armored motor vehicle service is not used in the transferring of money & securities? Are trips scheduled at irregular intervals and over varying routes? 16. Is there a rule against cashing cheques bearing rubber stamp signatures? 17. Cheques in excess of a specified amount require approval of a supervisor before being cashed? 18. Will there ever be only one staff member on premises at any give time? 19. How many employees are working at any given time? Average # With respect to items presented above: Secured Area means an area within the insured location where money & securities are retained. Money means currency, coins, banknotes, bullion, gold & silver jewellery Securities means negotiable and non-negotiable instruments or contracts representing either money or other property and includes revenue and other stamps in current use, tokens and tickets but, does not include money. GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 7 of 7