Application For Commercial Umbrella Liability Insurance Intact Insurance Company All Questions Must be Answered Completely. PLEASE PRINT. Agent/Broker Head Office: 1200-321 6 th Ave SW Calgary, AB T2P 4W7 Policy No. Date: General Information Name of Applicant, including all subsidiary companies, domestic and foreign: Applicant is: A Corporation A Partnership An Individual Other: Address: Other Locations: Give complete description of all operations: Annual Payroll $ Annual Sales/Receipts $ No. of Employees Are any additional operations or locations anticipated during the policy period? Yes No If yes, explain: Are all locations and operations to be covered?? Yes No If no, explain: Policy Period Desired: Limits Desired: From To $ in excess of underlying or retained limit $ retained limit or self-insured retention (must not be less than $10,000). Umbrella Application (03.2006) Page 1 of 5
Previous Umbrella Carrier a. Name of Carrier: b. Has any carrier cancelled, declined or refused coverage in past 3 years? Yes No If yes, explain: Coverage Trigger Coverage Trigger in underlying CGL: Occurrence Claims-Made Note: If Claims-Made, please contact your underwriter for details about Excess coverage. Description of Exposures 1. Automobile Liability a) State number of units owned and leased and registered in the name of the Applicant: Private Passenger Light Trucks / Vans: Heavy Trucks - Van type: Heavy Trucks - other than Van-type (State type & number): Tractors: Trailers: Buses: (Seating Capacity) Emergency Vehicles - Police, Fire & Ambulance (State type & number): b) Are volatile, corrosive, explosive or toxic materials hauled? Yes No If yes, explain (including type, quantity and frequency): c) Are any units engaged in long haul (over 100 miles)? Yes No If yes, explain and state number and type of units: d) State in which Province(s) you have vehicles registered? If any vehicles are registered in Quebec state number and type of vehicle: e) Is any hauling done for others? Yes No If yes, provide details of goods hauled including maximum radius of operations: f) Do any of the commercial vehicles travel regularly in the U.S.? Yes No If yes, provide details (including frequency, distance and States traveled in): 2. General Liability: a. Does the underlying policy have the following extensions? Occurrence Property Damage Broad Form Property Damage Blanket Contractual Liability.. Advertising Liability.. Personal Injury Employees as Additional Insureds... Products / Completed Operations. Vendor s Endorsement. Yes No Yes No Employer s Liability... Contingent E.L. Non-Owned Automobile Tenant s Fire Legal Liability. Blasting.. Underpinning Collapse b) Describe specifically the Products and / or Completed Operations and give sales for each: c) Have any products been discontinued during the past 5 years? Yes No If yes, list products and reasons: d) Are any products used or installed in any aircraft or missile? Yes No If yes, explain: e) Does applicant have any sales in U.S.? Yes No If yes, describe the product and the annual sales: Umbrella Application (03.2006) Page 2 of 5
f) Does applicant have any sales in other countries? Yes No If yes, describe the products, the name of the country and the annual sales: g) Does applicant sell or distribute products of any foreign manufacturers? Yes No If yes, specify product and country of origin: h) Attach sales brochure or advertising material if available. i) List principal customers: j) List operations performed by independent contractors. State percentage of total receipts: 3. Non-owned Property - Care, Custody and Control: a. List all leased real estate properties: Location Occupancy Estimated Value b. List all other property in the care, custody or control of applicant. (Include such property as electronic equipment, leased automobiles, machinery, material on consignment, under bailment, propertystored, etc.): Location Type Estimated Value 4. Aircraft and Watercraft: List and describe any 1. non-owned, leased or chartered aircraft: 2. owned, leased or chartered watercraft: 5. Worker s Compensation: a. Are all employees covered by Worker s Compensation? Yes No If no, explain: b. If not, is Employer s Liability carried on those employees not covered by Worker s Compensation? Yes No 6. Professional Liability: a. Is there any professional or errors or omissions exposure? Yes No If yes, explain: b. Is there any incidental malpractice exposure? Yes No If yes, is it covered by underlying policies? Yes No 7. Advertising Liability: a. Is any advertising contemplated during the policy term? Yes No If yes, explain type and state expenditure. b. Is an advertising agency used? Yes No 8. Contractual Liability: Give details of agreements in which the applicant assumes the liability of others: Umbrella Application (03.2006) Page 3 of 5
9. Pollution Liability: a. Is underlying General Liability policy subject to Standard I.B.C. Pollution Exclusion? Yes No If no, explain: b. Is Limited Pollution Liability required on Umbrella Policy? Yes No If yes, attach a copy of the underlying pollution coverage wording. 10. Liquor Liability: a. Does applicant s operations include the serving of alcoholic beverages? Yes No b. If yes, is it excluded by underlying policies? Yes No If no, what is underlying limit of liability? Underlying Insurance Type Carrier Policy No. Policy Period Policy Limits Annual Premium Auto C.G.L. Non-Owned Auto Employer s Liability Professional Liability Advertising Liability Contractual Liability Tenant s Legal Liability Other Non-Owned Property Liquor Liability Does any Policy listed above contain: 1. A Deductible? Yes No 2. A reduced limit of liability for any exposure? Yes No 3. A territorial restriction, e.g., U.S. products? Yes No 4. A single policy aggregate? Yes No If yes to any of the above, provide details: Umbrella Application (03.2006) Page 4 of 5
Loss History Describe all losses paid or reserved over $10,000 occurring during the past 5 years: Completion of this application does not bind the company to complete the insurance. It is agreed, however that this application shall form the basis of the contract, should the policy be issued by the Company. We know of no other relevant facts which might affect the Company s judgement when considering this application. Date: Agent/Broker s Signature Umbrella Application (03.2006) Page 5 of 5