Premier Canada Assurance Managers Ltd. Is One of Canada S Largest Managing Underwriting
APPLICANT
Broker: / Date:
1. Qualifications & Roofing Experience: (include photocopies of all tickets)
(a) Certificates Held (List):
(b) No. of Yrs. Experience: / Insured: / Employees:
2. Type Of Roofing Performed:
Commercial / Industrial / Residential
Hot Built Up / Receipts / $ / $ / $
Hot Mop / Receipts / $ / $ / $
Hot Air Membrane / Receipts / $ / $ / $
Torch on Membrane / Receipts / $ / $ / $
Cold Shingle Shakes, Metal Cladding / Receipts / $ / $ / $
Cold Membrane & EPDM / Receipts / $ / $ / $
Other (specify) / Receipts / $ / $ / $
Total: / $ / $ / $
Canadian: % / United States: %
3. Describe Hot Air Membrane Process:
4. Percentage Split: New Construction: / Re-Roofing & Repairs:
5. Any other off premises work (e.g. sheet metal), please describe:
6. Describe fully the measures taken to prevent fire at job sites (Please provide a copy of safety and fire prevention manual):
7. Are portable smoke detector used? / YES NO
8. Are spray-on fire retardants used? / YES NO
9. Is smoking prohibited on the roof? / YES NO
10. Is a supervisor on site during all operations involving hot stuff or torches? / YES NO
11. Describe fully the measures taken to prevent water damage (from rain and other sources) arising from the job site (including details of how roof areas are covered during repair & reproofing work):
12. Please provide details of propane take storage, maintenance & safe handling:
13. Are personnel engaged in the handling & operation of propane tanks trained? / YES NO
Please provide a copy of training manual.
14. Is each propane tank equipped with approved, operational safety valves? / YES NO
15. Does the applicant take precautions to properly store equipment and hazardous materials at job sites after working hours?
If yes, please provide safety and security details.
16. Are torch system manufacturers’ specifications followed? / YES NO
17. Are roofing material manufacturers’ specifications followed? / YES NO
18. Are torch stands used? / YES NO
19. Is each torch equipped with a functioning ULC listed regulator? / YES NO
20. Is all equipment fitted with operating pressure gauges? / YES NO
21. Are hot air welders or electric heat seaming devices used? / YES NO
22. Does the applicant ensure that all work is inspected at the end of each day and on completion of job? / YES NO
23. Is the applicant a member in good standing of The Provincial Roofing Contractors Association? / YES NO
24. Subcontractors YES NO
If yes, Please provide estimated receipts and describe work performed for applicant:
25. Is a formal contractual agreement entered into with sub-contractors? / YES NO
If yes, please submit a copy of the usual contract form.
26. Is any work covered under Wrap? YES NO If yes, estimated receipts:
27. Are “Certificates of Insurance” obtained from all subcontractors? / YES NO
28. Are there any Architects, Engineers, Consultants or similar professionals on staff? / YES NO
If yes, please describe:
29. Is the applicant ever engaged in the removal & disposal of asbestos? / YES NO
If yes, please provide full details:
30. Is an Umbrella Policy required? / YES NO
If yes, please advise the limits:
Signature of applicant / Date
Broker Name / Date
Premier Canada Assurance Managers Ltd. is one of Canada’s largest Managing Underwriting Agents. The underwriting insurance carrier varies by line of business and region - please refer to specific quote for declaration of the underwriting insurance company(s).
** Email application and attachments to - **Vancouver - T 604.669.5211 F 604.669.2667 / London - T 519.850.1610 F 519.850.1614
Rev. Oct 23, 2014