70 University Avenue, Suite 800
Toronto, Ontario M5J 2M4
Excess Liability Application
General Information
Name of Non-Profit Housing Corporation
/ HSC Number
Mailing address – Line 1
Mailing address – Line 2
City
/ Province
/ Postal Code
Contact Person
/ Position
Phone
() / Fax
Property Managers Details
1. Does your corporation performs any management activity on behalf of others? Yes No
If Yes, please complete the following:
Indicate all applicable categories under which your corporation provide professional services:
General Administration / Financial Management / Property Management
Tenants Placement Selection / Property Maintenance / Other (Please Describe)
2. Has your corporation previously carried Errors and Omissions Insurance: Yes No
If yes, please provide:
Insurer Name:
/ Policy Term:
3. Has any previous insurer ever cancelled or refuse to renew your property managers Errors and Omissions coverage?
Yes No
If yes, please provide details:
4. Has any claim for professional property management service been made against your corporation within the past 5 years?
Yes No
If Yes, please provide details:
5. Are you aware of any fact, error, omission or situation which may give raise to a professional liability claim?
Yes No
If Yes, please provide details:
Non-Shelter Tenant Support or Assisted Care Services Details
Does your or any other corporation owned or controlled provide Tenants Support or Assisted Care Services? Yes No
If Yes, Does your employees assist in providing these services? Yes No
If Yes, please provide details of the services provided
If No, Are Tenant Support or Assisted Care Services provided by others? Yes No
If Yes, is your corporation responsible to provide insurance coverage? Yes No
If Yes, please complete and provide the Tenant Support or Assisted Care Services application.
If No: Name the Corporation
Name the services provided
Do you require confirmation they maintain Commercial General Liability for a minimum of $1,000,000? Yes No
Do you require confirmation they maintain Professional Liability insurance for a minimum of $1,000,000? Yes No
insurance program application - declaration
Provide details of losses occurred within the past 3 years / Select if there are no losses within the past 3 years
Date of Loss (dd/mm/yyyy) / Cause of Loss / Reserve Amount / Amount Paid
$ / $
$ / $
$ / $
privacy wording
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 statements above.
Signature
Name (please print)
/ Signature (Signed by authorized officer, partner or principal)
Title
Date (mm/dd/yyyy)
Marsh is a registered trade-mark of Marsh LLC. HSC is a registered trade-mark of Housing Services Corporation.
130305fg-p Excess.doc (F13032583DT) 2014/06/27 Page 2 of 2