GENERAL APPLICATION
GENERALINFORMATION
Legal Name of Applicant
Mailing Address / Postal Code
Phone / Fax
Email / Website
Brokerage Name
Brokerage Address / Postal Code
Phone / Email
APPLICANT’SOPERATIONS (Give full description including: activities, programs, events, U.S. or international exposures)
OPERATIONS INFORMATION
How long has the Applicant been in operation? This Applicant is classified as For Profit Not-For-Profit
This Applicant is / Sole Proprietor / Partnership / Corporation / Unincorporated / (Other)
Date of incorporation
INSURANCE HISTORY
Current Insurer / Expiring Premium
Expiry Date / Target Premium
Is the current insurer offering renewal terms? / YES / NO
Are there any coverage restrictions being imposed by the present insurer?
LOSS/CLAIMS INFORMATION
Please describe any allegations; claims; or losses (including those relating to Abuse or Professional Negligence) in the past 5 years
including those without payment
Year / Type of Claim / Amount Paid / Reserve for Unpaid Claim
Are you currently aware of any circumstances which may reasonably be expected to give rise to a claim
that would be covered under any section of our policy? / YES / NO
Note that failure to provide information about any such circumstance may void coverage.
If "Yes", provide details.
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Name of the Regulatory body or legislation which oversees the Applicant’s OperationList all Associations the entity belongs to
Does the Insured have any subsidiary or affiliated entities? / YES / NO
If "Yes", please provide details
LIABILITY COVERAGES (OCCURRENCE FORM)
Liability Limit Requested / $
Tenant’s Legal Liability Limit Requested / $
Non-Owned Auto Limit Requested / $
Deductible Requested / $
LIABILITY INFORMATION
Number of employees: / Full Time / Part Time / Number of volunteers
If An Association - Number of members
Annual Payroll (Including Benefits) / Annual Revenue
Is Insured covered under Provincial Workman's Compensation Plan? / YES / NO
Identify and provide numbers of Professional Employees by category, and indicate whether they are full-time or part-time (ie: Nurses, Social Workers, Counsellors, Child and Youth Workers etc.)
Category / # of Full-Time / # of Part-Time
Describe all Fundraising events and show applicable receipts including liquor receipts where Insured holds Liquor License
Are any of the facilities rented to third parties? / YES / NO
If "Yes", do you get proof of Insurance? / YES / NO
Do Any Non-Medical Staff Administer Medication? / YES / NO
If "Yes", please describe
ABUSE
Is Abuse Liability Required? / YES / NO
Current Abuse coverage is / Occurrence / Claims Made
If Claims Made, what is the retroactive date required?
Abuse Liability Limit Requested / $
Are police records checked on all prospective employees and volunteers at least once every 3 years? / YES / NO
Please Note: Receipt and approval of an acceptable Abuse Protocol is required prior to binding.
ERRORS & OMISSIONS LIABILITY – Claims Made Form
Is Errors & Omissions coverage required? / YES / NO
Limit Requested / $ / Retro-active Date:
DIRECTORS' & OFFICERS'
Is coverage required? / YES / NO / # of Board Members / Annual Budget / $
FINANCIAL INFORMATION
This financial information must be furnished with respect to each Entity and each Benefit Program to be named in Item 1 of the policy DECLARATIONS. For the most recent fiscal year-end provide the following consolidated financial information:
a) / Total Assets: / $ / b) / Total Liabilities: / $
c) / Total Revenues: / $ / d) / Net Income: / $
For the current fiscal year, please indicate: / i) / Estimated Revenue / ii) / Estimated surplus/deficit
Binding subject to completed Not for Profit Directors' & Officers' Liability Application
CRIME COVERAGES
Is this coverage required? / YES / NO
Employee Dishonesty Form A, Commercial Blanket Bond Limit / $
Number of employees that handle Money-Securities etc. (Class A): / All Other employees:
Computer & Transfer Fraud Limit: / $
Credit Card Forgery Limit: / $
Broad Form Money & Securities – Loss Inside/Outside Premises Limit: / $
Limits Over $ 100,000. Require Completion of Crime Supplement
LEGAL EXPENSE COVERAGE
Legal Defence Costs Limit Required / $
Additional Information:
Provide full details of any lawsuits in the past five (5) years with respect to any Board Member, Director, Officer, Employee, Volunteer or Manager.
CYBER RISK INSURANCE
Is this coverage required? / YES / NO
If "Yes", complete Cyber Risk Insurance Short Form Application
ENVIRONMENTAL LIABILITY
Is coverage required? / YES / NO
Please fully describe exposure
Additional Supplements may be required.
BOARD MEMBER ACCIDENT
Is coverage required? / YES / NO / Limit Requested / $
Number of Board Members
PROPERTY COVERAGES
Note: Provide FULL REPLACEMENT COST VALUESON A PER LOCATION BASIS as our program does not
have co-insurance clauses or stated amount clauses
Note: A SITE PLAN including distances, is required for all buildings or locations situated within 150 feet of each other
Please complete Additional Property Supplemental Forms for Additional Locations – Available on our Website
Location address
Building Construction – Please indicate percentage for each type of construction
Fire Resistive (Concrete Walls; Roof; Floors) / %
Masonry Non-Combustible (Masonry walls; steel deck roof; concrete floors) / %
Non-combustible (steel on steel) / %
Masonry (Masonry walls; wood floors; wood roof) / %
All other (including Brick Veneer and Frame) / %
Occupancy by Insured / Occupied by Others as
Year Built / Year Updated: Plumbing / Heating / Wiring / Roof
Number of stories / Total area of building (including basement)
Is the building 100% sprinklered and centrally monitored? / YES / NO
Is the building 100% alarmed and centrally monitored? / YES / NO
What type of alarm? / Smoke / Heat / Intrusion
Distance to Fire Hydrant / Distance to Fire Hall
Heating System / Forced Air / Hot Water / Steam
Fuel Type / Gas / Electric / Oil / Wood
Describe secondary heating system (if applicable)
Asbestos: The following questions are applicable to all buildings built prior to 1980
Do any of the buildings that you own contain asbestos or asbestos products? / YES / NO
If "Yes"- Please provide full details as to whether or not buildings have been surveyed for both friable and non-friable asbestos materials
indicating the building, location, date surveyed and completed findings.
If "No"- has this been confirmed by a building survey? / YES / NO
Deductible requested / $
Building Limit / $ / If more than one building, provide PER building
Building is / Owned / Leased / If leased, a copy of the lease agreement is required
Tenants Improvements Limit / $
Outdoor Equipment (including playground, fencing and signs) Limit / $
Contents (including equipment and furniture) Limit / $
Extra Expense Limit / $
Additional coverages required (e.g. Flood, Earthquake, Fine Arts, etc.)
Are there additional buildings or locations? / YES / NO
Have you included all location and values that are owned, leased, rented or under the control of the
Insured? / YES / NO
If "No", please explain
DATA PROCESSING INSURANCE (Per Location)
Equipment/Hardware Limit / $ / Laptops / $
Media Limit / $ / Extra Expense / $
BUSINESS INTERRUPTION COVERAGES
Form Requested
Limit Requested / $
WORKPLACE DISRUPTION COVERAGE requested? / YES / NO
Limit Requested / $
Number of Locations owned and/or occupied by the Insured:
If "Yes", has any location ever been closed for infectious disease, contagion, food poisoning or vermin
infestation in the past 5 years? / YES / NO
If "Yes", please provide details
CRISIS MANAGEMENT COVERAGE requested? / YES / NO
Limit Requested / $
Please confirm in the past year the Named Insured (or any of their directors or officers) in relation to the Named Insured’s operations has not:
Defaulted on any debt obligation;Filed for bankruptcy reorganization under the bankruptcy and Insolvency Act of Canada; Been criminally charged under the Criminal Code of Canada; Had allegations with respect to bodily injury or death to or sexually abusedany person in the performance of his or her duties; Experienced a withdrawal or demand for return of any grant, contributionor bequestin excess of one hundred thousand dollars ($100,000); Had commencement of or threat of litigation or other proceedings by any governmental or regulatory agency;
If "Yes", please explain
EQUIPMENT BREAKDOWN INSURANCE
Is cover required? / YES / NO
Please confirm Replacement Value of all Electronic Equipment / $
If any single piece of equipment over $100,000., please describe.
Contact Name and Phone Number if different from page 1
Name / Phone Number
Any additional comments or coverages required
The Applicant acknowledges that the information contained herein and in any supplemental applications or forms required
is true, accurate and complete, and that no material facts have been supressed or misstated. The Applicant acknowledges
a continuing obligation to report to the Insurer as soon as practicable any material changes in all such information, after
signing the application and acknowledges that the Insurer shall have the right to withdraw or modify any outstanding
quotations and/or agreement to bind the insurance based upon such changes. If a policy is issued, the insurer will have relied
upon, as representations, this application, any supplemental applications, and any other statements furnished to the Insurer in
conjunction with the risk to be insured.
The undersigned, on behalf of the insured organization, acknowledges that any personal information provided in connection
with this application (including but not limited to the information contained in this form) has been collected in accordance with
applicable privacy legislation and this information shall only be used or shared by the Company to assess, underwrite and
price insurance products and related services, administer and service insurance policies, evaluate and investigate claims,
detect and prevent fraud, analyze and audit business results and/or comply with regulatory or legal requirements.
Date
Title/Position
Signature
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Frank Cowan Company
HEALTH AND WELLNESSSUPPLEMENTAL FORMIf operations include residents, does owner reside in the Facility? / YES / NO
List all Associations the Applicant belongs to and criteria for membership.
Has membership or registration ever been suspended, withdrawn, amended, declined / YES / NO
or had conditions attached?
If yes, please explain.
Has the Applicant ever been declined, non-renewed or cancelled by any Insurer? / YES / NO
If yes, please explain.
Current Liability coverage is:Occurrence Claims-Made
Current Liability Insurer:
Expiry Date: / Expiring Premium: / $
Current Professional/Malpractice coverage is:Occurrence Claims-Made
Current Professional/Malpractice Insurer:
Expiry Date: / Expiring Premium: / $
If Claims-Made indicate Retro Active Date Required:
Are all professionals licensed/certified to practice in the province? / YES / NO
If no, please explain.
How are qualifications of professional staff checked?
Do all qualified medical staff, including any interns, residents and fellows have CMPA coverage? / YES / NO
If Yes, do you obtain proof of CMPA coverage? / YES / NO
If No, please describe alternative insurance arrangements and for whom those arrangements apply.
Do any professional staff have liability/professional insurance coverage elsewhere? / YES / NO
Number of Residents/Beds if applicable
Annual number of client visits/clinical encounters
Number of day patient beds
Number of overnight beds
Maximum number of beds
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Frank Cowan Company
Is Applicant performing any of the following operations? / YES / NOSurgeries or invasive procedures.
Any in-home visits conducted (house calls)?
Research or teaching activities being conducted at the clinic?
Own or operate an ambulance service or any aircraft landing strip or pad?
Pathology laboratories?
Any prenatal services offered?
Any obstetric services offered?
Any Neonatal services offered?
Any midwifery services offered?
If Yes, please explain.
Are any other services offered with respect to the care of infants? / YES / NO
If Yes, please describe.
Does the Applicant or any of its employees perform activities outside of Canada or for patients residing outside of Canada?
Please provide details.
Percentage of gross annual income earned from citizens of the U.S. or other foreighn countries:
For patients from outside of Canada, is a Governing Law and Jurisdiction Agreement obtained in all cases? / YES / NO
Is your organization involved in sales and/or manufacturing of products or services for use outside / YES / NO
of the organization?
If Yes, please describe.
Please describe any activities outside the standard practice of medicine or the rendering of medical services (e.g. rental of offices, pay
parking, cafeteria, etc.)
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Frank Cowan Company
Does the applicant comply with all provincial guidelines with respect to: / YES / NONeedle stick injuries
Safe handling, collection & disposal of dressings, waste, blood/blood products and sharps
Patient lifting/moving
Infectious disease prevention & control
If No, please explain.
Does the Applicant have a functioning incident reporting system? / YES / NO
Does the Applicant provide facilities for the sterilization of instruments? / YES / NO
How long are Medical Records kept?
How and where are Medical Records stored?
Does your organization engage in any clinical trials or research and development involving / YES / NO
human test subjects?
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Frank Cowan Company