Broker Name: Broker Phone: Name of Insured: Insured Address: Telephone: Fax: Principals: Effective Description of Insured s Operations: How many losses has the Insured had in the last 5 years? CONTRACTORS APPLICATION Broker Fax: (Street, City, Province & Postal Code) Year Business Started: Date Amount Paid Amount Outstanding Deductible Description Insured Policy #: Has any insurer ever cancelled, refused or applied special terms to any similar insurance for Insured? If yes, please provide details: Are you aware of an occurrence that may lead to claim? If yes, please provide details: UNDERWRITING INFORMATION Building Construction: Height: Wall Construction: Roof Construction: Story(ies) Age of Building: years Square footage: by insured; by others Exposing Property: rth South East West Area (check all that apply): Industrial Commercial Residential Agricultural Urban Suburban Rural Upgrades (if more than 30 years): Roof: Details: Plumbing: Details: Heating: Details: Electrical: Details: Sprinklered: Heating: natural gas forced air lp gas hot water oil steam electric radiant other: other: Electricity: fuses non interchangeable breakers Wiring: Hydrant Protected: within feet Fire Department: within miles Does this business depend on any key equipment which may be difficult to replace? If yes, please explain: Page 1 of 5
PROPERTY COVERAGES Property Deductible 1,000 2,500 5,000 Building (Replacement Cost Value) Contents Extra Expense Rigging & Moving Nil 25,000 50,000 10,000 Flood Earthquake Sewer Backup Equipment Breakdown Miscellaneous Property Broad Form*: Nil Equipment Breakdown Scheduled Builders Risk Blanket Builders Risk Builders Risk Equipment Breakdown If yes, please complete Builders Risk Application If yes, please complete Builders Risk Application * Please provide a list of Miscellaneous Property items over 500, including a description and value for each item. CONTRACTOR S EQUIPMENT AND TOOL FLOATER Please complete Contractors Equipment & Tools Details Supplement (page 5 of this Application) Are any tools or equipment leased or rented from others? Equipment storage location: Maximum value of equipment and tools inside building: Does client have facilities for repairing or servicing own equipment? Is equipment serviced and overhauled on a regular basis in accordance with manufacturers guide? Are any pieces of equipment protected by tracking equipment (global positioning system locators)? If yes, please note when describing on details sheet. Contractor s Equipment 50,000 Contractor s Equipment Deductible 1,000 2,500 5,000 Rental Reimbursement Newly Acquired Contractor s Equipment Tools Newly Acquired Tools 25,000 250,000 10,000 50,000 * Any piece of equipment with a value of 2,500 or less should be included under tools (replacement cost value if 5 years or newer) ** Any tool with a value greater than 2,500 should be included under equipment (replacement cost value if 5 years or newer) INSTALLATION FLOATER* Type of property installed Name of installer or sub-contractor Installations rmally Inside Building Outside Building of jobs in progress at any one time: Estimated Annual Receipts: Average annual values installed Value of property at any one location: Maximum value in any one transit: Average Average Maximum Number of days to complete installation Maximum Average duration of transit: rmal method of transportation of property to be installed: *Installation Floater deductible matches property deductible. Is hot work ever done as part of a job? If yes, is a hot work permit system used? Installation Floater Limit 10,000 Page 2 of 5
CRIME Employee Dishonesty All Covers Except Employee Dishonesty Number of employees that carry money outside the premises (owners, accountants, messengers, etc..) LIABILITY Deductible 1,000 2,5000 5,000 Each Occurrence Limit 1,000,000 Tenants Legal Liability 100,000 n Owned Automobile 1,000,000 (Maximum Limit 5,000,000) Wrap-Up Liability Breakdown of Insured s Annual Income Construction Trade 5,000 (Included) 10,000 25,000 5,000 (Included) 10,000 25,000 2,000,000 3,000,000 4,000,000 5,000,0000 2,000,000 If yes, please complete Wrap-Up Application Gross Receipts Cost of Sub-Let Work Number of employees including part-time How many years of experience in the type of operations undertaken do the Insured and key employees have? Is casual or unskilled labour employed? Do you have any on staff professionals (architects, engineers, surveyors)? Do they perform original design work on projects? Do the on staff professionals carry errors and omissions coverage? If yes: Company Name Does the Insured carry SPF-4 Garage coverage? If yes: Company Name Please list your last projects: New Construction (NC) or Renovation (REN) Duration in Months Policy Number: Policy Number: Occupancy on Completion What percentage of operation is: Rural Urban Commercial Work Residential Work Do any operations take place outside of Canada? If yes, how often? Is equipment ever rented or leased to others without an operator? Are subcontractors required to carry liability insurance? If yes, what limit of liability insurance is required? Are certificates of liability insurance always obtained from subcontractors before they are allowed to commence work? Are formal contractual agreements entered into with subcontractors? Is any work carried out at any oil or natural gas production, exploration or processing facility? Check if completed or planned projects include any of the following: Blasting Logging or Lumbering Shoring or Underpinning Mining Structurall Steel Caissons Tunneling Dams Pile Driving Excavating Raising or Moving Buildings Welding Rigging Wrecking Gas Work Bridges Oil Field Work Use of Explosives Land Clearing Open Flame Work Page 3 of 5
OPTIONAL COVERAGE Extended business income: Amount of Gross Receipts Indemnity Period Ordinary Payroll: Limit Amount of Business Income Insurance 12 Months 18 Months 24 Months (Please attach completed Business Income Worksheet) CONSENT in accordance with the Act Respecting the Protection of Personal Information If it should be necessary for the purpose of my for the time required to fulfill their functions: (A) Gather all the pertinent necessary information from the holders of my prior insurance files, intermediaries in the insurance industry, insurance companies, financial institutions, credit agencies, government records establishing driving experience, prevention, detection, or repression of crime agencies and institutions that gather and compile data on insurance risks and losses. for the purpose of establishing the premium and the assessment of risk; and, (if you would like to consent now) for the purpose of verification, assessment and the settlement of losses; Furthermore, I authorize my broker to sign on concerning me. (B) Disclose, in the case of my broker, the information obtained to insurers with whom he is doing business; ; when it is my insurers, to institutions that gather and compile data on insurance risks and losses and prevention, detection or repression crime agencies. Solely the employees, mandatories or representatives of my broker, insurers or of institutions referred to in this paragraph will have access to this information when required within the execution of their functions. Furthermore, I consent that holders of information concerning me and covered by the present consent be released from their confidentiality undertaking and that they convey the required information to my broker, my insurers, their employees, trainees or representatives. I acknowledge having been informed of my right to access to information obtained by virtue of the present consent and to have it corrected, if need be. Furthermore, I acknowledge having been informed that I may address all questions regarding the present consent to my broker and/or my insurers, their employees, trainees or representatives. This insurance application is considered to include all provisions for all forms to be issued in accordance with this contract. The total estimated policy premium is subject to adjustment. file, I, undersigned, the applicant specifically consent that my broker and my insurers, my behalf any request or form that may be necessary in order to gather information Signature of Applicant: Signature of Co-Applicant: Page 4 of 5
CONTRACTORS EQUIPMENT AND TOOL DETAILS SUPPLEMENT Name of Insured: Actual Cash Value of Equipment & Tools over 5 years old Replacement Cost of Equipment & Tools newer than 5 years old Item Model. Year Manufactured Serial Number Actual Cash Value Replacement Cost Value 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Page 5 of 5