CDECA Program Member Insurance New Business Application

Transcription

1 CDECA Program Member Insurance New Business Application SECTION 1: APPLICANT INFORMATION 1. Name of Business: 2. Are you Incorporated? 3. CDECA Membership Number: 4. Name of the Principal / Owner of the Business: Phone # Fax # Mailing Address City Province Postal Code Website Address 5. Do you Rent or Lease Office Space? SECTION 2: UNDERWRITING DETAILS Please Complete the Following Table: 6. Please indicate the types of decorating services your firm provides to your clients and the estimated revenues from each service. Please indicate 0 if your firm does not provide the service listed and/or if a subcontracting firm is performing the service. Service Provided: Residential decorating services: Commercial decorating services: Electrical services: Plumbing services: General contracting services: Landscape design services: * Structural design services: ** Product sales manufactured by a third party: (please list types of products and revenue breakdown below) Service Provided: *NOTE: Please request the supplemental designer application from LMS PROLINK if you provide structural design services. **NOTE: If you are purchasing CGL coverage and your product sales make up more than 50% of your total revenues then you MUST purchase products liability coverage under Option D below. CDECA APP LMS PROLINK: Page 1 of 6

2 7. a. Have you ever been the recipient of any allegations of professional negligence either in writing or verbally? b. Are you aware of any facts, circumstances or situations, which may reasonably give rise to claim, other than advised above? 8. Do you currently carry any Commercial General Liability or Professional Liability insurance? If YES please provide the following details below: Current Insurer: Policy #: a. Premium: E&O Limits of Insurance: CGL Limits of Insurance: Office Contents Limits of Insurance: Expiry Date: Expiry Date: Expiry Date: 9. Has any insurer ever declined, cancelled or imposed special conditions for any coverage for you or your entity in the past? If YES please give details: 10. Have you reported any Commercial General Liability or Office Property claims in the past 5 years? If YES please give details: PLEASE NOTE The minimum retained premium noted in the charts below indicate the amount retained by the insurer when it is GREATER than the following: 1. The prorated premium for a short term policy (the master policy expires June 1, 2014). 2. The earned premium for your time insured with ENCON in the event the policy is cancelled mid-term. SECTION 3: COVERAGE FOR E&O LIABILITY AND COMMERCIAL GENERAL LIABILITY INSURANCE Option A E&O Liability Only Please Note that Option A is for E&O Liability ONLY. Please select the appropriate premium: Option A E&O Protection for services provided by up to TWO accredited Interior Decorators or Designers as recognized by CDECA: 500,000 Limit per claim and 500,000 annual aggregate limit (0 deductible): ,000 Limit per claim and 1,000,000 annual aggregate limit (0 deductible): ,000,000 Limit per claim and 1,000,000 annual aggregate limit (0 deductible): ,000,000 Limit per claim and 2,000,000 annual aggregate limit (0 deductible): CDECA APP LMS PROLINK: Page 2 of 6

3 Option B Additional Professionals Please list all designated professionals working for your firm: Name of Professional: Job Position: The E&O policy premium in Option A will provide coverage for up to 2 professionals, INCLUDING YOURSELF. For firms with 3 or MORE professionals, you MUST purchase additional coverage. Please select the appropriate additional premium PER additional professional employed. AII coverage opted for must share the same limit of liability as that chosen in Option A above. Please select the appropriate premium: Option B Additional Professionals Per Professional 500,000 Limit per claim and 500,000 annual aggregate limit (0 deductible): ,000 Limit per claim and 1,000,000 annual aggregate limit (0 deductible): ,000,000 Limit per claim and 1,000,000 annual aggregate limit (0 deductible): ,000,000 Limit per claim and 2,000,000 annual aggregate limit (0 deductible): Option C Addition of Commercial General Liability ( CGL ) Please select the appropriate premium required: Option C CGL 1,000,000 limit per occurrence and 1,000,000 annual aggregate limit: 2,000,000 limit per occurrence and 2,000,000 annual aggregate limit: 3,000,000 limit per occurrence and 3,000,000 annual aggregate limit: 5,000,000 limit per occurrence and 5,000,000 annual aggregate limit: CDECA APP LMS PROLINK: Page 3 of 6

4 Option D Product Sales Liability Coverage If you are purchasing CGL coverage and your product sales make up more than 50% of your total revenues then you MUST purchase products liability coverage. Please note if you elect this coverage the limit selected MUST match that of the CGL limit selected above. This coverage can only be purchased with the CGL policy. Please select the appropriate premium required: Option D Product Sales Liability Coverage 1,000,000 limit per occurrence and 1,000,000 annual aggregate limit: 2,000,000 limit per occurrence and 2,000,000 annual aggregate limit: 3,000,000 limit per occurrence and 3,000,000 annual aggregate limit: 5,000,000 limit per occurrence and 5,000,000 annual aggregate limit: SECTION 4: PROPERTY AND CRIME INSURANCE Option E - Office Package - Property and Crime Insurance Please note you MUST have CGL insurance in place in order to be eligible for this coverage. Option E - Office Package 30,000 Business Contents (including Exterior Signs and Electronic Data Processing Equipment and Media) * excludes laptops *Higher limits available for additional premium I would like a quote for higher limits PLEASE NOTE If purchasing this coverage, a supplemental application will need to be completed. Please contact CDECA@LMS.CA to obtain a copy of this document. CDECA APP LMS PROLINK: Page 4 of 6

5 SECTION 5: PREMIUM CALCULATIONS PRORATED TO JUNE 1, 2014 IF APPLICABLE SUBJECT TO MINIMUM RETAINED PREMIUM Section 3 - Coverage for Liability Insurance Option A Errors & Omissions Insurance: + Option B Additional Professionals (if selected): + Option C CGL Coverage (if selected): + Option D Product Sales Liability (if selected): SUBTOTAL: PST (Ontario residents add 8%; Quebec residents add 9%; Manitoba residents add 8%): SECTION 3 TOTAL: Section 4 Property Insurance Option E Office Package(if selected): SUBTOTAL: PST (Ontario residents add 8%; Quebec residents add 9%; Manitoba residents add 8%): SECTION 4 TOTAL: SECTION 3 + SECTION 4 TOTAL: PROGRAM ADMINISTRATION FEE: GRAND TOTAL (SECTION 3 & 4 TOTAL + PROGRAM ADMIN. FEE ): ADDITIONAL FEES: Please not a 25 fee will be assessed for all cheques returned due to non-sufficient funds and/or any declined credit card payments. CDECA APP LMS PROLINK: Page 5 of 6

6 APPLICANT S CONSENT TO THE TRANSMISSION OF THE INFORMATION CONTAINED IN THE APPLICATION FORM I hereby acknowledge that the information collected in the Application form is acquired by my insurance broker to be transmitted to ENCON Group Inc. for the sole purpose of obtaining an insurance policy, and will be kept confidential. Moreover, I authorize ENCON Group Inc., its insurers or service providers to: Conduct verification, using outside sources, of the information contained in the Application form, in attached documentation and in subsequently provided documentation; In the event of a claim, transmit the submitted and verified information to loss adjusters, lawyers or other similar offices for the purposes of investigating, defending, negotiating or settling any claims, as required. For more information on ENCON s privacy policy, please contact privacy-officer@encon.ca. DECLARATIONS AND SIGNATURE The undersigned Applicant for this insurance declares that, to the best of his/her knowledge and belief, the statements set forth herein are true and correct and that reasonable efforts have been made to obtain sufficient information to facilitate the proper and accurate completion of this Application form. The undersigned further agrees that if any significant change in the condition of the Applicant is discovered between the date of this Application form and the effective date of the policy, which would render this Application form inaccurate or incomplete, notice of such change will be reported immediately in writing to the Insurance Manager. Although the signing of this Application form does not bind the Applicant to purchase the insurance, the undersigned Applicant agrees that this form and the information furnished pursuant hereto shall be the basis of the contract should a policy be issued and this form will become part of the policy. Applicant s Signature: Name (print): Date: Once completed, please submit this Application with a cheque payable to: LMS PROLINK Ltd. 480 University Ave, Suite 800 Toronto, ON M5G 1V2 If you have questions please contact: LMS PROLINK Ltd. CDECA Account Manager at FAX: or CDECA@LMS.ca CDECA APP LMS PROLINK: Page 6 of 6