Please Complete Thisform for Eachand Every Location for Which Coverage Isrequired

TERRORISM APPLICATION

[Please complete thisForm for eachand every location for which coverage isrequired]

A.INFORMATIONABOUTTHEAPPLICANT

1.CompanyName:
2.NamesofAllSubsidiaryCompanies:
3.HeadOfficeAddress:
4.OwnershipoftheCompany
[egPublic,Private,Government,etc]:
5.NationalityofOwnership:
6.DateofCommencementofOperations:
7.DescriptionofApplicant’sbusiness operations:
8.IsBusinessInterruptioncoverrequired? / Yes No
9.LimitofCoverrequired:
[singlecombinedlimiteachandevery lossandintheaggregateduringtheperiodofinsuranceforphysicaldamageandbusinessinterruption]
10.Has theapplicant,anyof itssubsidiaries oranyotherentitytobe insured underthispolicysufferedaloss,whetherinsuredornot,inthepastfiveyears froman incident of terrorismorsabotage? Ifyes,listthedate,location,typeofincidentandamountofloss: / Yes No
11.Has theapplicant,anyof itssubsidiaries oranyotherentitytobe insured underthispolicyreceivedanythreat(s)againsttheirassets(e.g.bombscares)?Ifyes,pleaseprovidedetails: / Yes No
12.Doestheapplicant,itsdirectorsandofficersoranyknownpersonhaveknowledgeorinformationthatmayreasonablygiverisetoaclaim?Ifyes,describetheknowledgeorinformation / Yes No

B.LOCATIONDETAILS

1.ZiporPostalCode
2.ValueofBuildings
3.ValueofContents
4.BusinessInterruptionValue[12months]
5.TotalInsuredValue
6.Isthereaguardforce?Ifyes,howmanyguards / Yes # No
7.ArethereintrusiondetectionsystemandCCTVsystems? / Yes No
8.Isthereaperimeterfence?
Ifyes,isitilluminatedatnight? / Yes No
Yes No
9.Isthereanaccesscontrolsystem?(e.g.cardaccessorsign‐inprocedure) / Yes No
10. Isthereaparkingarea?Ifyes,where?(e.g.withinthebuilding,outside,etc.) / Yes No
11.Descriptionoftheareasurroundingthelocation(e.g.rural,commercial,government,etc.,includingname(s)oflandmarks)
12.Arethereanyofthefollowingwithin500metresofthelocation?
a)MilitaryPremises?
b)GovernmentPremises?
c)TouristAttractions?
d)Airport/othertransportfacilities?
e)Landmarks?
f)Sportingvenues?
g)Religiousinstitutions?
h)InternationalHotels?
If“Yes”pleasegivefulldetails / Yes No
13.What,ifany,businessesoccupytheotherpartsofthe buildingandbuildings incloseproximity?

NOTICETOAPPLICANTS

ThisapplicationdoesnotbindtheApplicantorUnderwriters,butitisagreedthatthisapplicationwillbethebasisofthecontractshouldapolicybeissued.TheApplicantrepresentsthatiftheinformationsuppliedonthisapplicationchangesbetweenthedateofapplicationandtheinceptionofthepolicy,theApplicantwillimmediatelynotifytheUnderwritersofsuchchanges.

THEUNDERSIGNED AUTHORISEDOFFICER OFTHEAPPLICANTDECLARESAND WARRANTSTOTHEBESTOFHISKNOWLEDGETHATTHESTATEMENTSSETFORTHHEREINARETRUE,COMPLETEANDCORRECT.

AUTHORISEDSIGNATUREOFTHEAPPLICANT:

NAMETITLEOFAUTHORISEDOFFICER:

DATE:

ONTARIO
1-855-745-1010
/ QUEBEC
1-855-745-2020
/ REMAINDER OF CANADA
1-855-745-1010