ADR Program Professional Insurance and Commercial Insurance Renewal Terms July 1, 2012 Important News about the 2012 Professional and CGL Insurance Renewal We have been successful in completing renewal negotiations with your Insurer, Certain Underwriters at Lloyd s for the policy period, July 1, 2012 July 1, 2013 and are pleased to advise that we have been able to negotiate as is terms for the renewal term. The premiums remain the same as last year. The application should be completed and faxed to our office latest by June 22, 2012 with payment to allow us time to review your application and provide you with your renewal policy. Limit and premium chart provided on the application Instructions to calculate payment are provided on the application. Credit card authorization form to be used for payment. Should there be a variance due to tax calculations, we will use your credit card authorization to charge the difference. Mailing information for cheque to Marsh office available on the application Completed application can be faxed, scanned and emailed or mailed to our office. Certificate of Insurance will be sent to you by email. Please read and let us know if there are any changes required. Note: Policy jurisdiction is Canada which means that coverage is for ADR services including arbitration and mediation services provided in Canada and subject to policy terms and conditions. If coverage is required for ADR services provided outside of Canada, the application needs to be reviewed and approved by the insurer. Additional premium will apply if coverage is granted. ADMINISTRATION FEE Marsh will continue with an Administration Fee of 25.00 per Certificate for policies incepting July 1, 2012. 25 per Certificate fee will be in addition to the premium shown on the application.
ADR Program Professional and CGL Insurance Renewal Terms Page 2 IMPORTANT INFORMATION The Professional policy is a CLAIMS-MADE AND REPORTED policy which requires that all claims against you or incidents which arise that may result in a claim during the policy period be reported immediately to the Insurer before the expiration of the policy. It is prudent that you report claims or circumstances before July 1, 2012 to avoid denial of coverage. The Commercial General policy is an Occurrence based policy. If you have any questions, please call your Service Team, Theresa Mukoyi or Ruby Noronha at +1 888 711 9010 or email us at errorsandomissions.insurance@marsh.com Thank you for continuing to be a Marsh client and we look forward to servicing you this year! Sincerely, Janet Lobo Assistant Vice President Professional Services Team This document and any recommendations, analysis, or advice provided by Marsh (collectively, the "Marsh Analysis") are intended solely for the entity identified as the recipient herein ("you"). This document contains proprietary, confidential information of Marsh and may not be shared with any third party, including other insurance producers, without Marsh s prior written consent. Any statements concerning actuarial, tax, accounting, or legal matters are based solely on our experience as insurance brokers and risk consultants and are not to be relied upon as actuarial, accounting, tax, or legal advice, for which you should consult your own professional advisors. Any modeling, analytics, or projections are subject to inherent uncertainty, and the Marsh Analysis could be materially affected if any underlying assumptions, conditions, information, or factors are inaccurate or incomplete or should change. The information contained herein is based on sources we believe reliable, but we make no representation or warranty as to its accuracy. Except as may be set forth in an agreement between you and Marsh, Marsh shall have no obligation to update the Marsh Analysis and shall have no liability to you or any other party with regard to the Marsh Analysis or to any services provided by a third party to you or Marsh. Marsh makes no representation or warranty concerning the application of policy wordings or the financial condition or solvency of insurers or reinsurers. Marsh makes no assurances regarding the availability, cost, or terms of insurance coverage. Marsh is one of the Marsh & McLennan Companies, together with Guy Carpenter, Mercer, and Oliver Wyman. Copyright 2012 Marsh Canada Limited and its licensors. All rights reserved. www.marsh.ca www.marsh.com MARSH
ADR Insurance Professional and CGL Term: July 1, 2012 to July 1, 2013 IMPORTANT NOTICE REGARDING THE REPORTING OF CLAIMS AND CIRCUMSTANCES Your professional liability policy is written on a claims-made and reported basis. This means that only CLAIMS made and reported during the policy term will be accepted for payment consideration, subject to policy terms and conditions. As such, it is imperative that you immediately report CLAIMS or potential incidents which may give rise to a CLAIM. Please refer to the claims contact information at the end of this document for CLAIMS and circumstances reporting details. Failure to follow the CLAIMS reporting guidelines will result in the denial of a CLAIM. The claims contact information sheet is attached below for your reference and ease of processing. Please report all matters directly to Marsh Claims Department in Toronto and our Claims Department will report to your insurers. Policy Claim Reporting Terms: This explanation of the reporting provisions of your policy has been provided in order to assist you in understanding and complying with the policy s requirements. In the event of a question or disagreement with your insurer concerning interpretation of the policy s reporting requirements as applied to the reporting of a specific CLAIM, LOSS, occurrence, incident, offence, or lawsuit, the actual policy wording, which is the contract between you and the insurer, and not Marsh s explanation of that language, will be controlling. Marsh, as an insurance representative, does not provide legal advice, and this explanation should not be relied upon as legal interpretation of the policy provisions.
ADR PROFESSIONAL LIABILITY AND CGL INSURANCE CLAIMS CONTACT INFORMATION In the event that you become aware of a claim or circumstance which may give rise to a claim, you should immediately provide notice directly to Marsh Canada as follows: MARSH CANADA LIMITED Claims Department Brookfield Place 161 Bay Street, Suite 1400 Toronto, ON M5J 2S4 Email: toronto.claims@marshcanadaclaims.com Toll Free Phone No. +1 855 627 7454 Toll Free Fax No. +1 866 556 7083 MARSH
If you have questions regarding the completion of this form please contact Marsh Canada s Professional Service Team at: Toll Free: +1 888 711 9010 Insurance Application Form For Members Of The ADR Institute Of Canada Certain Underwriters At Lloyd s Of London PLEASE ANSWER ALL QUESTIONS, SIGN AND DATE THIS FORM AND RETURN IT TO OUR OFFICE WITH PAYMENT A. GENERAL INFORMATION Salutation Mr. Mrs. Ms. Dr. Applicant Name Name of Business Type of Business Sole Proprietor Partnership Corporation Others Mailing Address (City) (Province) (Postal Code) Telephone Home ( ) Date Operations Began Month Date Year Office ( ) Gross Annual Fees/Income Fax ( ) Previous Year E-Mail Anticipated this Year 1. Are you a member in good standing of the ADR Institute of Canada? Yes No Note: Membership dues must be current (paid) to your local/provincial ADR Institute office to be eligible for this policy. 2. Have any claims (whether insured or not) ever been made against you in the last 5 years? Yes No (If yes, please attach full details.) 3. Are you aware of any act, error, omission or circumstance which could give rise to a claim brought against you Yes No in the last 5 years? (If yes, please attach full details.) 4. Have you been subjected to any disciplinary action brought against you by your professional association? Yes No (If yes, please attach full details.) 5. Has an application for liability insurance ever been declined? Yes No (If yes, please attach full details.) Effective date of your first ADR Professional Policy: Month Day Year (Note: Coverage should be continuous and without any gap.) 6. Do you provide services in Canada for clients who are outside of Canada? Yes No (If yes, please provide details.) 7. Do you provide services outside of Canada or perform activities outside of Canada? Yes No (If yes, please provide details.) What percentage of your revenue is derived from the following Province(s) or Territory(ies): British Columbia % Alberta % Saskatchewan % Manitoba % Ontario % Quebec % New Brunswick % Nova Scotia % PEI % Newfoundland and Labrador % Yukon % Northwestern Territories % Nunavut % Total Percentage : (must be total 100%) % * Sales Tax will be applied accordingly on revenues for Province where it is required. B. PROFESSIONAL LIABILITY INSURANCE Have you been previously insured with Claims-Made Professional? If yes, please provide details below. Yes No Insurer Policy Limit Policy Period Coverage Options Option 1 Option 2 Option 3 1,000,000 per claim 2,000,000 aggregate 10,000,000 shared aggregate Deductible - 1,000 136.00 Annual Cost Deductible - 500.00 146.00 Annual Cost 2,000,000 per claim 4,000,000 aggregate 10,000,000 shared aggregate Deductible - 1,000 190.00 Annual Cost Deductible - 500.00 200.00 Annual Cost An Administration Fee of 25 is collected by Marsh in addition to commission. 3,000,000 per claim 6,000,000 aggregate 10,000,000 shared aggregate Deductible - 1,000 244.00 Annual Cost Deductible - 500.00 259.00 Annual Cost 120207fx-p-New.doc 2012-04-17 Page 5 of 8
C. COMMERCIAL GENERAL LIABILITY INSURANCE Coverage Options Option 1 Option 2 Option 3 Option 4 Option 5 1,000,000 per claim 1,000,000 per aggregate 500,000 Tenants Legal 1,000,000 Standard 2,000,000 per claim 2,000,000 per aggregate 500,000 Tenants Legal 1,000,000 Standard 3,000,000 per claim 3,000,000 per aggregate 500,000 Tenants Legal 1,000,000 Standard 2,000,000 per claim 2,000,000 per aggregate 1,000,000 Tenants Legal 2,000,000 Standard 3,000,000 per claim 3,000,000 per aggregate 1,000,000 Tenants Legal 2,000,000 Standard Deductible -500 178.00 Annual Cost Deductible -500 223.00 Annual Cost Deductible -500 267.00 Annual Cost Deductible -500 267.00 Annual Cost Deductible -500 321.00 Annual Cost For purposes of the Insurance Companies Act (Canada), this document was issued in the course Lloyd s Underwriters insurance business in Canada. PAYMENT SCHEDULE 1) Applicable Tax for Premium only: ON 8% Sales Tax QC 9% Sales Tax 2) Applicable Tax for Administration Fee only: ON (8% PST) = 2.00 AB / NT / NU / PE / SK (5% GST) = 1.25 BC (12% HST) = 3.00 NB/NL (13% HST) = 3.25 NS (15% HST) = 3.75 MB/YT No Fee Allowed QC (5% GST) + (9.5% QRT Services) = 3.74 Professional : General (add, if selected) : (a) Total Premiums: (b) Add: Tax (refer to the Table 1) : (c) Add: Administration Fee* 25.00 (d) Add: Tax (Refer to Table 2) : TOTAL PAYABLE sum of (a) to (d) : * NOTE: For applicants resident in the Province of Manitoba or in Yukon Territory, no administration fee applies. Do NOT add Item (c) to the Total Payable Payment Type: Cheque (Issue to Marsh Canada Ltd.) Credit Card (Visa or MasterCard) WITHDRAWAL OF PAYMENT IS NOT PROOF OF INSURANCE. THE POLICY DOCUMENTS MUST BE ISSUED TO CONFIRM COVERAGE. THE INSURANCE PREMIUMS ARE FULLY RETAINED AND WILL NOT BE REFUNDED. D. IMPORTANT INFORMATION (a) Please note that the common expiry date for all coverages is July 1 st. Policies issued mid term are calculated on a pro-rata basis subject to minimum premium and applicable sales tax. (b) The premium is fully retained and non-refundable. (c) The Professional is on a claims-made and reported basis which requires that all claims or incidents which may arise be reported during the policy period. (d) This application does not bind the applicant or the company to complete the insurance, but it is agreed that this form shall be the basis of the contract should the policy be issued and it will be attached to and made a part of the policy. The applicant agrees that if the information supplied on the application changes between the date of the application and the time when the policy is issued, that applicant will immediately notify the company of such information. Any misrepresentation, omission, concealment or incorrect statement of material fact, in the application or otherwise, shall be grounds for cancellation of any policy issued in reliance upon such information. E. STEPS REQUIRED TO SECURE COVERAGE 1) Please complete and sign the application and return to Marsh Canada Limited. You can send it either by fax, email or mail to the address below. 2) Upon receipt of signed and completed application, a Marsh representative will contact you in writing to advise if the application has been accepted or if there are any questions. 3) A Marsh representative will also confirm the premium owing. Please note that the common renewal date is July 1 st therefore the premium will be prorated subject to minimum premium and are fully retained. 4) Payment in the form of either a cheque payable to Marsh Canada Limited or credit card (Visa or Mastercard) must be received at Marsh within 2 business weeks from the submission of the application. Payment by CREDIT CARD: Please complete and sign the authorization form returning it to Marsh Canada Ltd. via fax (+1 416 868 8973 or +1 888 776 1250) along with the completed credit card authorization form. Please note that any minor variances due to taxes between the completed application form and the actual invoice will be adjusted when processing the credit card payment. or Payment by CHEQUE: Please complete and sign the application form returning with a cheque payable to Marsh Canada Ltd. Via Mail: P.O. Box 8991, Postal Station A, Toronto, ON M5W 2C5 Via Courier: Marsh Canada Limited, RBC Wholesale Remittance Dept., 4 Prince Andrew Place, Toronto, ON M3C 2H4 Attn: Lockbox #8991 5) Upon receipt of payment and a signed and completed application the insurance certificate will be issued and sent to you by email. 6) For COVERAGE/APPLICATION RELATED QUESTIONS or SUBMISSION OF COMPLETED APPLICATION, please contact : 120207fx-p-New.doc 2012-04-17 Page 6 of 8
A. PRIVACY COMPLIANCE ATTENTION: Professional Service Team Marsh Canada Limited 70 University Avenue, Suite 800, Toronto, ON M5J 2M4 Toll Free Phone No. : +1 888 711 9010 Fax: +1 416 349 4510 Toll Free Fax: +1 800 214 2471 Email: errorsandomissions.insurance@marsh.com PLEASE SIGN - DO NOT COMPLETE - FOR INFORMATION PURPOSES ONLY DECLARATION The Client hereby acknowledges that Marsh has been retained by the Client, the Association, and/or a member of the Association, which is a Client, to provide insurance coverage and products to its members and/or to acquire or renew a policy or policies of insurance or to provide Surety, Consulting, and/or Risk Management Services for the Client, Association and/or members of the Association, under which the Client, individual Client, named individual members of the Client, named individuals in addition to the Client, or where the Client is a commercial or other entity, its employees, servants and representatives (hereafter collectively called "insured individuals") may be insured. As part of the application for new or renewal insurance coverage(s) or to provide Surety, Consulting and/or Risk Management Services, the Client hereby authorizes and expressly consents to Marsh collecting, using or disclosing Personal Information of such insured individuals as required and as permitted pursuant to relevant privacy laws or other laws and providing such Personal Information to third parties as required, including insurance companies, intermediaries, reinsurers, other brokers, claims adjusters, the association if applicable, and other third parties involved in providing the above services as outlined in Marsh's Privacy Policy which can be viewed at www.marsh.ca or can be forwarded to the Client on request. Where there are insured individuals in addition to the Client, or where the Client is a commercial or other entity, the Client hereby covenants and warrants that the Client has obtained the appropriate consent from all of the insured individuals for its disclosure of their Personal Information to Marsh and to the collection, use and disclosure of their Personal Information by Marsh for these purposes and has either provided a copy of Marsh's Privacy Policy or referred the insured individuals to the Marsh.ca website. The Client agrees to indemnify and hold Marsh harmless for any claims arising from the Client s breach of this warranty. B. PROGRAM DISCLOSURE Your (Professional and/or Commercial General ) coverages will be placed with a program administered by Marsh Canada Limited. Marsh Canada has engaged in a competitive marketing process to offer a competitive product. We have negotiated this ADR Program on a group basis with insurers but we have not acted as a broker for any individual participant. C. COMMISSION DISCLOSURE Marsh Commissions: Coverage Type Insurer Name / Non-Wholesaler Premium () Commission Percentage (%) Non-Wholesaler Marsh Bermuda / London etc. Intermediary Commission (%) Admin Fee () Enhanced Commission (%) Professional 136.00 25 NIL Professional 146.00 25 NIL Professional 190.00 Marsh UK Retail 25 NIL 30% Professional 200.00 7.5% 25 NIL Professional 244.00 25 NIL Professional 259.00 25 NIL General 178.00 N/A NIL General 223.00 N/A NIL Marsh UK Retail General 267.00 30% N/A NIL 7.5% General 267.00 N/A NIL General Certain Underwriters at Lloyds of London 321.00 Notes: 1. Enhanced Commissions - In some circumstances, the Enhanced Commission may only apply to a portion of the premium. 2. Marsh Canada Limited has a Global and/or National Fee for Service arrangements with certain insurers, which remunerate Marsh and its affiliates, on a fixed fee for services basis, for market consulting services provided to such insurers. For further details, please contact your Client Executive. For disclosures with respect to the items below, please refer to www.marsh.ca > About Us > About Marsh > Disclosure: Marsh & McLennan Companies, Inc. and its subsidiaries own equity interest in a number of insurers and have contractual arrangements with certain insurers and wholesale brokers. Information on the above is available as indicated above. Premium Financing Marsh Income disclosure statement SIGNATURE Name Date (mon/dd/yyyy) N/A NIL Signature 120207fx-p-New.doc 2012-04-17 Page 7 of 8
Credit Card Authorization Fax: +1 888 776 1250 Payment by credit card will expedite the processing of your application. PLEASE PRINT CLEARLY YOUR PAYMENT CANNOT BE TRANSACTED UNLESS ALL SECTIONS OF THIS AUTHORIZATION FORM ARE COMPLETED Card Type: Visa Mastercard Personal Name as shown on the Credit Card Card Number: Expiry Date: Month Year WITHDRAWAL OF PAYMENT IS NOT PROOF OF INSURANCE COVERAGE. THE POLICY DOCUMENTS MUST BE ISSUED TO CONFIRM COVERAGE. *** ANY ADJUSTMENTS WILL BE PROCESSED AS A SEPARATE TRANSACTION. Please note:. It is your responsibility to provide us with up to date credit card information. If you fail to do so and you miss a payment because we are unable to charge your credit card, your insurance policy may be cancelled for non-payment. If you need to change your billing details, please contact the National Cash Receipts Group immediately or submit a new form. Cardholder Signature: Transaction Amount: () Payment in respect of: Program Name : ADR INSTITUTE OF CANADA Named Insured: Invoice# or Client # : FOR OFFICE USE ONLY Transaction Date: DR Tracking # (if applicable): PRIVACY: Have you read Marsh's Privacy Policy which is available at www.marsh.ca? Do you consent to the collection, use, disclosure and retention of your Personal Information as set out in the Privacy Policy, and do you understand that you may (subject to certain restrictions and consequences) later withdraw your consent as to any or all of the purposes identified in that Policy? By signing this form you are consenting to the Privacy statements above. Name (please print) SIGNATURE Signature Date (mon/dd/yyyy) PLEASE FAX YOUR COMPLETED AND SIGNED CREDIT CARD AUTHORIZATION FORM TO THE NATIONAL CASH RECEIPTS GROUP SECURE FAX NUMBER: +1 888 776 1250 031202ft-P.doc: 2005/11/07 Page 8 of 8