Commercial Application GIG

COMMERCIAL PROPERTY APPLICATION

1.Name ofBroker:

2.PhoneNumber:FaxNumber:

3.Name ofInsured: ContactPerson: Title: PhoneNumber:

4.MailingAddress:

5.Name ofEvent:

6.Location of Risk:

7.Occupancy:

8.OtherOccupancy(ies):

9.Website:

10.Loss Payee /Morgagee

11.PolicyTerm:From:To:

12.Expiry date of prior coverage if different from effective date listedabove:

13.COVERAGES:PROPERTY

FireNamedPerilsBroadForm

ReplacementCostActual Cash Value

Amount ofInsuranceCo-InsuranceRateDeductiblePremium

Building$
Equipment$
Stock$ / %
%
% / $
$
$ / $
$
$
$ / % / $ / $
$ / % / $ / $
BusinessInterruption
Form:$ / % / $ / $
Rents$ / 100% / $ / $
$ / % / $ / $
$ / % / $ / $
$ / % / $ / $
$ / % / $ / $
$ / % / $ / $
Other:

BURGLARY ANDROBBERY

Comprehensive Dishonesty, Disappearance & DestructionRider

I Commercial Blanket Bond, Form A$$ II Loss Inside (10% overnight limitation when not kept in safe) $ $ III Loss Outside $ $

IVMoney Orders and Counterfeit PaperCurrency$$

VDepositorsForgery$$

COMMERCIAL PROPERTY APPLICATION

BroadFormMoneySecurities(10%overnightlimitationwhennotkeptinsafe)$$

Inside/OutsideRobbery$$

Damage to Building byBurglary$$Description ofSafe:

Is there an ATM at any of the Insured’spremisesYesNo

If yes,Details:

EQUIPMENT BREAKDOWNCOVERAGEBroadFormComprehensiveForm

AirCondition:YesNoDetails: Limit per accident: $

Perishable StockLimit:$

14.UNDERWRITING INFORMATION – please attach photo ofrisk

BuildingConstruction / Height: / Story(ies)
WallConstruction:
Age ofBuilding: / RoofConstruction: / Squarefootage:byinsured;byothers

ExposingProperty:North:South:East:West:

Area (checkallthatapply)industrialcommercialresidentialagriculturalurbansuburbanrural

Upgrades (if older than 30years

Roof:YesNoDetails:Date: Plumbing: Yes No Details: Date: Heating: Yes No Details: Date: Electrical: Yes No Details: Date:

Sprinklered:YesNo

Heating:naturalgaslp gasoilelectricOther: forced air hot water radiant steam Other Electricity: fuses non interchangeablebreakers Wiring:

HydrantProtected:YesNowithinfeet/meters ofpremisesFireDepartment: within miles/ kilometers

Does this business depend on any key equipment which may be difficult toreplace?YesNoIf yes, pleaseexplain:

RETAILRISKS:
Is there any food prepared or cookingdone?
If yes, providedetails: / / Yes / No
Is there a deep fat fryer orgrill?
Describe automatic extinguishingsystem: / / Yes / No
Any Tobacco or Liquor Productssold? / / Yes / NoMaximum Amount:$
If yes, provide details of storage andcages:
Is there a floor maintenance program inplace?Are daily sweep logskept? /
/ YesYes / No (please attach copy)No

15.BURGLARY/THEFTPROTECTION–attachalarmcertificatefrommonitoringcompanyifapplicable

Name of MonitoringCompany: Name of AlarmSystem:

Insured has been inbusinessyears;or

This is a NewVenture.

If this is a new venture, describe the principals prior businessexperience:

16.PREVIOUS INSURANCE AND LOSSHISTORY

PreviousInsurer(s): PolicyNumber(s): Expiring Premium (ifknown):

Has any Insurer cancelled or declined to renew a policy of insurance for thisapplicant?Yes No

If yes,explain: No claims or incidents in the last 5 years of operation.

No claims or incidents – NewVentureUnknown – no priorinsurance

Claims / incident history (5years):

Date ofClaimDescriptionAmountPaidExpensesDeductible

Any uninsured losses in the past 5years?YesNo

If yes,explain:

Completedby:Date:

17.CONSENT in accordance with the Act Respecting the Protection of PersonalInformation

If it should be necessary for the purpose of my file, I, undersigned, the applicant specifically consent that my broker and my insurers, forthe time required to fulfill theirfunctions:

(A)Gather all the pertinent necessary information from the holders of my prior insurance files, intermediaries in the insuranceindustry,insurance companies, financial institutions, credit agencies, government records establishing driving experience, prevention, detection,orrepression of crime agencies and institutions that gather and compile data on insurance risks andlosses.

-for the purpose of establishing the premium and the assessment of risk; and, (if you would like to consentnow)

-for the purpose of verification, assessment and the settlement oflosses;

Furthermore, I authorize my broker to sign on my behalf any request or form that may be necessary in order to gather informationconcerningme.

(B)Disclose, in the case of my broker, the information obtained to insurers with whom he is doing business; when it is my insurers,toinstitutions that gather and compile data on insurance risks and losses and prevention, detection or repression crime agencies. Solelytheemployees, mandatories or representatives of my broker, insurers or of institutions referred to in this paragraph will have access tothisinformation when required within the execution of theirfunctions.

Furthermore, I consent that holders of information concerning me and covered by the present consent be released from theirconfidentialityundertaking 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,ifneedbe.

Furthermore, I acknowledge having been informed that I may address all questions regarding the present consent to my broker and/ormyinsurers, their employees, trainees orrepresentatives.

This insurance application is considered to include all provisions for all forms to be issued in accordance with thiscontract.The total estimated policy premium is subject toadjustment.