ࡱ> 7 %bjbjUU 47|7|!El>>>>>>>Rh?h?h?8?L@R~k<BT@J"bJbJbJbJzL~M"e$e$e$e;_e/hj$l nD#k>NbJbJNN#kO>>bJbJ8kOOONp>bJ>bJ"eON"eOOP>>PbJB ~rR<h?rNPPNk0~kPpOpPORR>>>>TYPS General Insurance Program Application Form (Please note: double click on boxes to check them off) All questions are to be answered as completely as possible. If a question is not applicable to your situation state N.A. If insufficient space is provided, please attach full details. Organization Information: Name: Postal Address: Address:City:Province:Country:Postal Code:Phone:Web Site:Fax:E-mail:More phone numbers:  FORMCHECKBOX  Main  FORMCHECKBOX  Direct  FORMCHECKBOX  Toll  FORMCHECKBOX  Fax  FORMCHECKBOX  Pager  FORMCHECKBOX  Cell  FORMCHECKBOX  Home  FORMCHECKBOX  Other FORMCHECKBOX  Main  FORMCHECKBOX  Direct  FORMCHECKBOX  Toll  FORMCHECKBOX  Fax  FORMCHECKBOX  Pager  FORMCHECKBOX  Cell  FORMCHECKBOX  Home  FORMCHECKBOX  Other FORMCHECKBOX  Main  FORMCHECKBOX  Direct  FORMCHECKBOX  Toll  FORMCHECKBOX  Fax  FORMCHECKBOX  Pager  FORMCHECKBOX  Cell  FORMCHECKBOX  Home  FORMCHECKBOX  Other Contacts: Position: Accountant CEO Insured Manager Owner President Principal/Partner Secretary Vice President Other: Main Direct Toll Fax Pager Cell Home Last NameFirst NameMr./Ms./Dr.PositionPhoneE-mailOther Business Operations: Description of operations: Typical Activities -  Claims Information: Loss DateTypeDescriptionAmount PaidReserve Previous Policy Information: Insurer:Broker:Policy #:Premium:Prev. Term:From:To: If renewal was not being offered please explain below:  Location Information: General: Location number:This location is  FORMCHECKBOX  Urban  FORMCHECKBOX  RuralAddress:City:Province:Country:Postal Code: Risk Information: Construction: Stories: Walls: FORMCHECKBOX  Reinforced Concrete FORMCHECKBOX  Steel Framed Masonry  FORMCHECKBOX  Steel Framed Non-Masonry  FORMCHECKBOX  Solid Brick FORMCHECKBOX  Brick Veneer FORMCHECKBOX  Wood Frame & all others Roof: FORMCHECKBOX  Steel deck FORMCHECKBOX  Tar paper FORMCHECKBOX  Tar & Gravel FORMCHECKBOX  Metal FORMCHECKBOX  Slate FORMCHECKBOX  Tile FORMCHECKBOX  Asphalt shingles FORMCHECKBOX  Wood shingles FORMCHECKBOX  Wood shakes FORMCHECKBOX  Rubber FORMCHECKBOX  Plastic FORMCHECKBOX  Other describe Floors: FORMCHECKBOX  Reinforced Concrete FORMCHECKBOX  Concrete in Metal Pan FORMCHECKBOX  Wood Frame  Area: FORMCHECKBOX  Ft  FORMCHECKBOX  mYear built: Basement: FORMCHECKBOX  Concrete  FORMCHECKBOX  Stone/Block  FORMCHECKBOX  Not Applicable Electrical: FORMCHECKBOX  Breakers FORMCHECKBOX  Fuses FORMCHECKBOX  Breakers & fuses Plumbing: FORMCHECKBOX  Copper FORMCHECKBOX  Lead FORMCHECKBOX  Plastic (PVC or CVS) FORMCHECKBOX  Galvanized FORMCHECKBOX  Stainless steel FORMCHECKBOX  Steel Heating: FORMCHECKBOX  None FORMCHECKBOX  Duct furnace FORMCHECKBOX  Boiler FORMCHECKBOX  Radiant FORMCHECKBOX  Electric FORMCHECKBOX  Heat Pump FORMCHECKBOX  Furnace (central) FORMCHECKBOX  Floor furnace FORMCHECKBOX  Space heater FORMCHECKBOX  Other describe Fuel: FORMCHECKBOX  Oil FORMCHECKBOX  Natural gas FORMCHECKBOX  Propane FORMCHECKBOX  Steam FORMCHECKBOX  Wood FORMCHECKBOX  Electric FORMCHECKBOX  Other describe Renovations:  FORMCHECKBOX  None known:  FORMCHECKBOX  Electrical:Year:Complete/Partial: FORMCHECKBOX  Plumbing:Year:Complete/Partial: FORMCHECKBOX  Heating:Year:Complete/Partial: FORMCHECKBOX  Roof:Year:Complete/Partial: Fire Protection: Hydrants: FORMCHECKBOX  Unprotected FORMCHECKBOX  Within 150m FORMCHECKBOX  Within 300m FORMCHECKBOX  Over 300m Fire: FORMCHECKBOX  Not specified FORMCHECKBOX  Within 5k FORMCHECKBOX  Within 8k FORMCHECKBOX  Within 13kDepartment: FORMCHECKBOX  Over 13k Extinguishing: System Type: FORMCHECKBOX  Portable Extinguisher(s) FORMCHECKBOX  Sprinkler FORMCHECKBOX  None FORMCHECKBOX  Comb. Portable & Sprinkler FORMCHECKBOX  Other (describe) Fire Alarm: FORMCHECKBOX  None FORMCHECKBOX  Complete FORMCHECKBOX  Central Station FORMCHECKBOX  Monitoring station (full) FORMCHECKBOX  Monitoring station (shared) FORMCHECKBOX  Local alarm FORMCHECKBOX  Other (describe)Coverage: % FORMCHECKBOX  Standpipe & hose Other: Crime Protection: Protection Types: FORMCHECKBOX  Doors deadbolt FORMCHECKBOX  Breakage resistant glass  FORMCHECKBOX  Windows - barred  FORMCHECKBOX  Surveillance cameras FORMCHECKBOX  Entrance visible from street FORMCHECKBOX  Exterior doors of sturdy construction, inside hinges FORMCHECKBOX  Property/lot illuminated at night Burglar Alarm: FORMCHECKBOX  None FORMCHECKBOX  Complete FORMCHECKBOX  Partial FORMCHECKBOX  Central Station FORMCHECKBOX  Monitoring station (full) FORMCHECKBOX  Monitoring station (partial) FORMCHECKBOX  Local FORMCHECKBOX  Other (describe) Occupancy: Insured: Others: Exposures:  FORMCHECKBOX  Clear all directions: Left of Insured:Right of Insured:Behind Insured: Liability Information: Business Information: In business since:# of employees : f/t:p/t: FORMCHECKBOX  Covered by WCB Exposure rating basis: Revenue: Annual gross receipts:Canadian %:US %:Foreign %:Area of Premises Square Feet: Attendance: Current - Total # of individuals over a year Average per day Last year Total # of individuals Average per day Employees: Current Last year Liquor liability: Is there any liquor liability: FORMCHECKBOX  Yes  FORMCHECKBOX  NoReceipt splits:Liquor $:Food $:Other $: Notes: Misc.: Notes: Policy Information: Period of Coverage: From:To: Schedule of Coverages PROPERTY Limit FORMCHECKBOX  Building, Equipment and Stock FORMCHECKBOX Broad  FORMCHECKBOX Named FORMCHECKBOX  Building  FORMCHECKBOX  Replacement Cost FORMCHECKBOX  Equipment  FORMCHECKBOX  Replacement Cost FORMCHECKBOX  Stock FORMCHECKBOX  Contents of Every Description (COED) FORMCHECKBOX Broad  FORMCHECKBOX Named FORMCHECKBOX  Equipment  FORMCHECKBOX  Replacement Cost FORMCHECKBOX  Stock BUSINESS INTERRUPTIONLimit FORMCHECKBOX  Extra Expense FORMCHECKBOX Broad  FORMCHECKBOX Named CRIMELimit FORMCHECKBOX  Comprehensive 3 D FORMCHECKBOX  Depositors Forgery FORMCHECKBOX  Money & Securities FORMCHECKBOX Broad  FORMCHECKBOX Robbery FORMCHECKBOX  Money Orders & Counterfeit Paper Currency LIABILITYLimit FORMCHECKBOX  Commercial General Liability (Occurrence Form) FORMCHECKBOX  Directors & Officers Liability FORMCHECKBOX  Profit  FORMCHECKBOX  Non profit FORMCHECKBOX  Non-Owned Automobile Liability (SPF 6) FORMCHECKBOX  Tenants Legal Liability FORMCHECKBOX Broad  FORMCHECKBOX Limited MACHINERY BREAKDOWNLimit FORMCHECKBOX  Machinery Breakdown The undersigned is authorized by the Directors and Officers of the Organization to complete this application and declares that to the best of his/her knowledge and belief the statements set forth herein are true. I may have provided personal information in this document and by other means and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this information, subject to the law and to my brokers or insurance companys policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, renewals, changes of coverage, evaluating claims, detecting and preventing fraud, and analysing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf. 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