Specialty Lines Insurance
Comprehensive Corporate Liability Insurance – Application
Private Corporations
If a policy is issued, the coverage will apply only to claims that are first made against the insured during the policy period.
General Information- Name of Parent Corporation:
- Mailing Address
- The following officer is designated as agent of the Corporation to receive any and all notices from the Insurer or its authorized representatives concerning this insurance:
Name / Title
- Nature of business:
- Does the corporation provide any professional services?
- Website:
- The Corporation has continuously been in business since: and, is incorporated under the laws of:
- Please provide the following information, as of the date of this Application:
CANADA / U.S.A. / OTHER
a)Total number of employees, including subsidiaries / Unionized:
Non-unionized:
TOTAL: / Unionized:
Non-unionized:
TOTAL: / Unionized:
Non-unionized:
TOTAL:
b)Number of employees with salaries over $100,000
c)Number of locations
d)Total number of shareholders
- Within the past 3 years, has the Parent Company or any subsidiaries thereof been involved in, or is considering,
- Do you have any operational subsidiaries in U.S.A. where at least one person on the Board of Directors is an
- During the next 12 months, does the Corporation expect to increase its presence in the U.S.A.?YES NO
If “YES” to one or more questions above, please provide full details on a separate sheet.
- Name and give a percentage of the holdings of any shareholder of the Corporation named above who owns 10% or more of the voting shares directly or indirectly:
% / %
% / %
Financial Information
Most Recent Year End / CANADA / U.S.A. / OTHER
Current Assets / $ / $ / $
Total Assets / $ / $ / $
Current Liabilities / $ / $ / $
Long Term Debt / $ / $ / $
Equity / $ / $ / $
Revenues / $ / $ / $
Net Income (Net Loss) / $ / $ / $
(a)Is the Corporation currently or has it at any time during the past three years sought protection under the “Companies Creditors Arrangement Act” (Canada), or does it anticipate seeking such protection within the next 12 months? / YES NO
(b)Is the Corporation currently or has it during the past three years been in breach of any debt covenants, loan agreements or contractual obligations, or is any such breach anticipated in the next 12months? / YES NO
(c)Is the Corporation currently or has it during the past three years been in arrears of its payments to Revenue Canada or the provincial ministries of revenue, including source deductions, H.S.T., G.S.T., Q.S.T., and P.S.T.? / YES NO
(d)Does the Corporation derive more than 25% of its annual revenue from one customer? / YES NO
If “YES” to one or more questions above, please provide full details on a separate sheet.
Employment Practices Liability Coverage
Is Employment Practices Liability coverage sought by the Corporation?YES NO
Please answer the following additional questions only if Employment Practices Liability coverage is required.
- Does the Corporation have a Human Resources Department?
- Does the Corporation have or use:
(a)an employee handbook distributed to all employees? / YES NO
(b)a written policy against discrimination and sexual harassment? / YES NO
(c)outside counsel for advice on employment or labour-related matters? / YES NO
(d)Is the Corporation considering any layoffs, staff reduction or facilities closing within the next two (2) years? / YES NO
- When an employee is terminated:
(a)is officer approval required? / YES NO
(b)is Human Resources personnel or legal consulation directly involved? / YES NO
Fiduciary Liability Coverage
Is Fiduciary Liability coverage sought by the Corporation? / YES NO
Please answer the following additional questions only if Fiduciary Liability coverage is required.
1.Name(s) of Pension Plan(s)
2.Date established:
3.Sponsorship: Single employer Multi-employer (collectively bargained) Other
4.Defined benefit planDefined contribution planOther Specify:
- Has the pension plan been converted from a defined benefit plan to a defined contribution plan?
If yes, date of conversion:
- Is the plan adequately funded and solvent as attested to by an actuarial valuation?
(a)Total plan assets ($000):
(b)Surplus/(Loss) according to the last actuarial valuation: / YES NO
(c)Number of participants:
- Has any plan ever been involved in a prohibited transaction?
- Has any plan been terminated in the past year?
- Are there any overdue employer contributions for any plan?
Prior Insurance
Prior insurance (do not complete if this is a renewal application for an existing policy with IntactInsurance):
Within the past three years, has the Corporation had any insurer refuse to renew or cancel the Directors and Officers, Employment Practices or Fiduciary Liability Insurance? / YES NO
Directors and Officers / Employment Practices / Fiduciary
Limit of liability
Deductible
Expiry date
Loss History
Loss history (do not complete if this is a renewal application for an existing policy with IntactInsurance):
In the past three years, has any director, officer or the Corporation been involved in any:
(a)actions, proceedings or investigations alleging a violation of any securities law or regulation, antitrust law or restraint of trade law or regulation? / YES NO
(b)insolvency or bankruptcy proceedings? / YES NO
(c)criminal actions? / YES NO
(d)representative actions, class actions or derivative suits? / YES NO
(e)claims under a Directors and Officers, Employment Practices or Fiduciary Liability Insurance policy, or given notice of a potential claim to the insurer? / YES NO
Prior Knowledge/Warranty
Prior knowledge (do not complete if this is a renewal application for an existing policy with IntactInsurance):
NOTE: Continuity of coverage will be granted whenever IntactInsurance is the current provider of the insurance applied for.
(a)Is any claim pending against any person or entity proposed for this insurance? / YES NO
(b)Is any person proposed for this insurance aware of any facts or circumstances likely to give rise to a claim? / YES NO
If “YES” to questions (a) and/or (b) above, please provide all details on a separate sheet.
WITHOUT PREJUDICE TO ANY OTHER LEGAL REMEDY AVAILABLE TO THE INSURERS, IT IS AGREED THAT ANY CLAIMS KNOWN TO THE INSURED OR ARISING FROM FACTS OR CIRCUMSTANCES KNOWN TO THE INSURED WILL BE EXCLUDED FROM THIS PROPOSED COVERAGE.
Declaration for the Application
The undersigned declares that:
(a)he or she has been duly authorized by the Corporation to complete this Application and that all statements contained herein are true and complete;
(b)reasonable efforts have been made to obtain sufficient information from each person proposed for this insurance in order to complete this Application properly and accurately;
(c)the financial statements submitted with this Application reflect the current financial situation of the Corporation and its subsidiaries (if this is not the case, please provide details on a separate sheet).
The undersigned agrees that:
(a)if between the date of this Application and the effective date of the policy, the statements and information contained in this Application change in any way, he or she will immediately advise IntactInsurance in writing and, without prejudice to any other legal remedy available to it, IntactInsurance may modify or withdraw any outstanding quotation or any authorization or agreement to bind;
(b)this application and all documents attached hereto shall form part of the policy, should one be issued.
Signature / Position (Chairperson of the Board, President or General Manager)
Date / Corporation
Upon request only, please provide the following additional information:
−The latest Audited Financial Statements and latest Interim Statements;
−The latest Financial Statements of the Plan(s);
−The most recent Actuarial Valuation Report;
−Organizational chart of the Corporation (Parent Company)
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