Ontario Application for Automobile Insurance - Garage Form (O.A.P. 4) Policy No. Assigned New Policy Renewal Replacing Policy No. Language Insurance Company Broker Ensurco Preferred Insurance Group English French ITEM APPLICATION INDICATE 1. FULL NAME OF THE APPLICANT FULL BUSINESS ADDRESS (ALSO PROVIDE POSTAL ADDRESS IF DIFFERENT) (A) BLDG. LOT LOCATION OF OTHER PREMISES WHERE BUSINESS IS CONDUCTED (SHOW EACH BUILDING AND LOT SEPARATELY) (B) (C) (D) Year Month Day TO Year Month Day 2. POLICY PERIOD FROM 12:01 AM ALL TIMES ARE LOCAL TIMES AT THE APPLICANT S POSTAL ADDRESS 3. THE AUTOMOBILES IN RESPECT OF WHICH INSURANCE IS TO BE PROVIDED ARE THOSE USED IN CONNECTION WITH THE APPLICANT S BUSINESS OF: Tire sales and installation (SPECIFY WHETHER AUTOMOBILE DEALER, REPAIR GARAGE, SERVICE STATION, OR PARKING LOT AND DESCRIBE ALL OTHER BUSINESS IN RESPECT OF WHICH INSURANCE IS TO BE PROVIDED, CONDUCTED BY THE APPLICANT AT THE LOCATIONS SPECIFIED IN ITEM 1). NOTE: THIS FORM SHOULD NOT BE USED FOR RENTAL OR LEASING EXPOSURES 4. THE BASIS OF RATING AND CALCULATION OF THE PAYABLE SHALL BE IN ACCORDANCE WITH THE COMPUTATION STATEMENT ATTACHED HERETO ESTIMATED TOTAL PAYROLL FOR POLICY PERIOD: NUMBER OF EMPLOYEES INCLUDING PROPRIETORS, Owner PARTNERS AND EXECUTIVE OFFICERS AT THE operated EFFECTIVE DATE OF THE POLICY. 5. THIS APPLICATION IS MADE FOR INSURANCE AGAINST ONE OR MORE OF THE PERILS MENTIONED IN THIS ITEM BUT ONLY FOR INSURANCE UNDER THE SECTION(S) OR SUBSECTION(S) FOR WHICH A IS SPECIFIED IN THIS ITEM AND NOT OTHER AND UPON THE TERMS, CONDITIONS, PROVISIONS, DEFINITIONS AND EXCLUSIONS OF THE CORRESPONDING ONTARIO GARAGE AUTOMOBILE POLICY 4, FOR THE FOLLOWING SPECIFIED LIMITS AND AMOUNTS. Section 1 THIRD PARTY LIABILITY INSURING AGREEMENTS Bodily Injury COMPANY USE ONLY THIRD PARTY INCLUSIVE LIMIT 2,000,000 Property Damage BASIC BENEFITS Income replacement; up to per week Section 2 ACCIDENT Caregiver & Dependant Care OPTIONAL BENEFITS ACCIDENT INCREASED BENEFITS Medical, Rehabilitation & Attendant Care Death & Funeral FULL TIME PART TIME ADVANCE Section 3 UNINSURED AUTOMOBILE COVERAGE Section 4* DIRECT COMPENSATION PROPERTY DAMAGE Section 5** LOSS OR DAMAGE TO OWNED Indexation As stated in Section 3 of the policy DIRECT COMPENSATION - PROPERTY DAMAGE DEDUCTIBLE APPLICABLE TO EACH SEPARATE AUTOMOBILE NIL This policy contains a partial payment of recovery clause for property damage if a deductible is specified for Direct Compensation -- Property Damage. 5.1.1 5.1.2 COLLISION OR UPSET DEDUCTIBLE APPLICABLE TO EACH SEPARATE AUTOMOBILE - THE UNDER SUBSECTIONS 5.1.2, 5.1.3 and 5.1.4 SHALL BE CALCULATED ON A MONTHLY AVERAGE BASIS OR CO-INSURANCE BASIS OR OTHER COMPREHENSIVE (EXCLUDING COLLISION OR UPSET AND OPEN LOT THEFT) LOCATION AS PER ITEM 1 SUB- SECTIONS INSURED LIMIT OF LIABILITY* DEDUCTIBLE APPLICABLE TO EACH SEPARATE OCCURRENCE (EXCEPT FOR LOSS OR DAMAGE BY FIRE, LIGHTNING, OR THEFT OF THE ENTIRE AUTOMOBILE) COMPANY USE ONLY (A) (B) AUTOMOBILES 5.1.3 SPECIFIED PERILS (EXCLUDING OPEN LOT THEFT) 5.1.4 SPECIFIED PERILS EXCLUDING THEFT (C) (D) *THE LIMIT OF LIABILITY FOR EACH AUTOMOBILE IS THE ACTUAL CASH VALUE AT THE TIME OF LOSS NOT EXCEEDING THE ACTUAL COST TO THE INSURED AND IS SUBJECT TO THE STATED LIMIT AND APPROPRIATE CO-INSURANCE CONDITIONS APPLICABLE TO THE MONTHLY AVERAGE BASIS OR CO-INSURANCE BASIS OF RATING. 1
Section 6** 6.1 COLLISION OR UPSET **This policy contains a partial payment of loss clause. LIMIT APPLICABLE TO ANY ONE CUSTOMERS AUTOMOBILE DEDUCTIBLE APPLICABLE TO EACH SEPARATE OCCURRENCE LIABILITY FOR DAMAGE TO A CUSTOMER S AUTOMOBILE WHILE IN THE CARE, CUSTODY OR CONTROL OF THE APPLICANT LOCATI ON AS PER ITEM 1 MAXIMUM NUMBER OF CUSTOMERS AUTOMOBILE S LIMIT OF LIABILITY ANY ONE OCCURRENCE 6.4 SPECIFIED (A) 2 PERILS (EXCLUDING OPEN (B) LOT THEFT) (C) DEDUCTIBLE APPLICABLE TO EACH SEPARATE OCCURRENCE (EXCEPT FOR LOSS OR DAMAGE BY FIRE, LIGHTNING OR THEFT OF THE ENTIRE AUTOMOBILE) COMPANY USE ONLY (D) O.E.F. 81 - Garage Family Protection Endorsement Yes No LIMIT Limits are the same as Section 1, or OTHER ENDORSEMENTS OEF GARAGE FAMILY PROTECTION NAME AND ADDRESS OF LIENHOLDER OR MORTGAGEE TO WHOM JOINTLY WITH THE APPLICANT LOSS UNDER SECTION 4 & 5 IS PAYABLE NIL MINIMUM RETAINED TOTAL ADVANCE THE ADVANCE S ARE SUBJECT TO THE ADJUSTABLE COMPUTATION PROVISION IN THE POLICY 6. HAS ANY INSURER CANCELLED, DECLINED OR REFUSED TO RENEW ANY INSURANCE RELATED TO THE BUSINESS OF THE APPLICANT WITHIN THE THREE YEARS PRECEDING THIS APPLICATION? IF SO, STATE NAME OF INSURER AND POLICY NO. NO 7. STATE PARTICULARS OF ALL ACCIDENTS, LOSSES OR CLAIMS ARISING OUT OF THE OWNERSHIP, USE OR OPERATION OF ANY AUTOMOBILE (S) BY (i) THE APPLICANT (ii) IN CONNECTION WITH THE BUSINESS, WITHIN SIX YEARS PRECEDING THIS APPLICATION (LIST SEPARATELY IF NECESSARY). DATE BI PD AB DC-PD LIA COLL COMP/SP.PERILS Y/M/D Owned Customer Owned Customer NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL 8. PROVIDE DETAILS OF APPLICANTS MOST RECENT AUTO INSURANCE POLICY # new INSURER: ITEM NO. REMARKS EXPIRY DATE YY MM DD 9. DECLARATION OF APPLICANT Read this section carefully before you sign. Where 1 an Applicant for a contract, (i) gives false particulars of the applicant s automobile exposures to be insured to the prejudice of the Insurer; or (ii) knowingly misrepresents of 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, a claim by the Insured, for other than such Accident Benefits as are set out in the Statutory Accident Benefits Schedule, is invalid and the right of the Insured to recover indemnity is forfeited. I am applying for automobile insurance based on the information provided above. With respect to this application or any renewal or change to the coverage, I authorize you to collect, use and disclose information for the purposes necessary to assess the risk, investigate and settle claims, and detect and prevent fraud, such as credit rating, driving record information and claims history. Signature of Broker/Agent Signature of Applicant Date June 7, 2011 2
SUPPLEMENTARY UNDERWRITING AND RATING INFORMATION 1. OPERATIONS: List the operation(s) of the Applicant showing the approximate Gross Revenue(s) generated by each for the past year. SALES New Vehicles SERVICE: Oil, Lube REPAIRS : Used Vehicles INSTALLATION: Motorcycles SALE OF FUEL, OIL: Body PARKING: By Customer Mechanical By Employee Rental or Leasing (describe): Other (describe): 2. TOTAL NUMBER OF EMPLOYEES & PAYROLL Full Time Part Time Actual Full Amount of Payroll Past Year new business 2 nd Year Prior 3. SUMMARY OF *ACTIVE AUTOMOBILES OWNED BY THE INSURED i NOTE: *Renting or leasing of automobiles to others is excluded other than shown in iv below. ) Completed Application *If automobiles are leased by the insured from others they must be insured on a separate policy (O.A.P. 1) in the name of the Lessor with an O.P.C.F.5 ) ) for Owners form (O.A.P. 1) *Towing services also require separate policy O.A.P. 1 ) is required (a) COMMERCIAL TOW TRUCKS (strictly incidental to a garage operation) (b) PARTS & SERVICE TRUCKS NUMBER iv COURTESY CARS (Exclusively supplied to customers whose own vehicles is being serviced, repaired or awaiting delivery of a new vehicle) ii DEMONSTRATORS v MISCELLANEOUS AUTOMOBILES iii (vehicles used for test drives, including Salesmen s cars) AUTOS SUPPLIED (Excluding Demos) for regular & frequent use of: (a) Active Partners & Full Time Employees (b) Others (These persons should be listed on O.E.F. 76 see question 7(B) vi (i.e. Motorcycles, Motor Homes, Shuttle Buses, other - specify) NUMBER OF DEALER PLATES HELD (Excluding those permanently attached to vehicles counted in Sections i to v) If less than 5 automobiles owned, list all owned vehicles (excluding motorcycles, snowmobiles, trailers, etc) NUMBER YEAR MAKE & MODEL BODY TYPE LIST PRICE NEW GVW USE DRIVEN BY Total Of Active Owned Automobiles Past Year 1 st Prior Year 2 nd Prior Year 3
4. PREMISES DETAILS 1) 2) LOCATION OF BUILDING(S) CONSTRUCTION DETAILS 3) Number of vehicle exits? Loc.1 Loc.2 Loc.3 Are any obstructed? No Yes (If Yes at any location, please describe & include Location number) Can vehicles be easily removed in emergency? Yes No (If No, please explain & include Location number) List details of protection at each location (i.e. lights, fenced yard (height), watchman, isolated location, alarm, etc.) 1) Premise is secured by rolling shutter doors and protected by burglar alarm serviced name to be advised 2) 3) Describe procedure for handling and storage of keys for the vehicles (during and after business hours). During Business Hours: After Business Hours: 5. TYPES AND VALUES OF AUTOMOBILES CARS, LIGHT TRUCKS Maximum Unit Value Average Unit Value Maximum Number OTHER (specialized vehicles, heavy trucks, recreational, i.e. ATV, snowmobile, motorcycle) OWNED CUSTOMERS OWNED CUSTOMERS BLDG. LOT BLDG. LOT BLDG. LOT BLDG. LOT 6. MAXIMUM VEHICLES PER LOCATION (if legal liability, specified perils, comprehensive is required for customers vehicles) Building (A) (B) (C) (D) Open Lot (A) (B) (C) (D) 7. A. List all company officials and full time employees who are supplied with owned vehicles for their regular or frequent use, or who usually drive owned or customers automobiles, including parts and Tow Truck Drivers. (TYPE A) B. List all operations other than full time employees who are supplied with owned vehicles for their regular or frequent use (e.g. spouses, daughters, sons, sports personalities, etc.) and all operators named on an O.E.F 76 Additional Insured Endorsement. (TYPE B) C. All employees who operate vehicles in the course of their duties. (TYPE C) Type Name License Number C Date of Birth Years License d Position/Relationship to Insured Years Employed C C 4
List all convictions (past 3 years) for above Drivers N.B. If insufficient space, please attach a complete list NAME DATE TYPE OF CONVICTION N.B. If insufficient space, please attach a complete list Losses damage to or by owned automobiles in the past 3 years (6 years if less than 5 vehicles owned) AMOUNT PAID DATE TYPE OF LOSS (including expenses) DESCRIPTION DAMAGE TO CUSTOMER S AUTOMOBILES IN THE CARE, CUSTODY OR CONTROL OF THE APPLICANT N.B. If insufficient space, please attach a complete list. 8. Does applicant: (a) Provide Shuttle Service for Customers? Yes No (b) Pick up or deliver customer s automobiles? Yes No 9. (a) Does applicant pick up or deliver owned or customer s vehicles in a radius in excess of 80KM (50 Miles)? (i.e. Taken elsewhere for undercoating, modification or sale/purchase?) Yes No If yes, please explain NA (b) Any U.S. exposure? Yes No If Yes, explain NA 10. Do Salesmen always accompany customers who are test driving automobiles? Not applicable If No, described other precautions taken (i.e. Driver s license checked and recorded)? 11. Does applicant dispense propane, do propane conversions, repair or maintain propane fuel system? Yes No If Yes, give details 12. Motor Vehicle Abstracts Are they obtained for all new employee drivers? Yes No If Yes, how often updated? 5
13. Does applicant have written rules regarding use of demonstrators? Not applicable If Yes, attach a copy. Is demonstrator use restricted to employees only? Not applicable Including Spouses? Yes No Including Children? Yes No 14. Does applicant repair, sponsor, or operate any vehicle modified for racing? Yes No If Yes, give details 15. Does applicant hire any other drivers (on a casual basis) who may operate automobiles? Yes No If Yes, give details 16. Applicant s previous Insurer(s) and Policy Number(s) prior 3 years INSURER POLICY NUMBER 17. AGENT/BROKER REPORT (A) How long have you known applicant? New business (B) Is business new to your brokerage? Yes No (C) Does the applicant have other insurance with our Company? Yes No Provide details, including Policy Numbers. (D) Is coverage required for financed automobiles? Yes No If Yes, state Name & address of lienholder ADDITIONAL INFORMATION/UNDERWRITER S NOTES Agent/Broker Signature Applicant s Signature Date: June 7, 2011 6