COMMERCIAL UMBRELLA LIABILITY APPLICATION

Applicant
Individual	Joint Venture	Partnership	Corporation	Other- Specify:
Name:	Mailing Address:
Website:
How long has the applicant been in business with the same principals?
Description of operations:	Annual Payroll	Annual Sales	# Employees
Attach a list of all properties owned or managed by the applicant. Identify occupancy and construction. Attach a descriptive brochure of products.
Subsidiary Companies
List all Subsidiary Companies:
Name and address of Company	Description of Operations	Annual Payroll	Annual Sales	# Employees
Does the applicant or subsidiary companies have any operations of sales outside of Canada? Yes No. If yes, provide complete details. Attach descriptive brochure and any other pertinent documentation relative to ‘products’ and provide any details of any foreign operations below.
Name of Company	Description of Operations	Country	Annual Payroll	Annual Sales	# Employees
Are all companies listed above to be covered by this insurance? Yes No If No, provide details of all exceptions.
Schedule of Underlying Policies
Policy #	Insurer	Policy period	Coverage	# of Claims	Limits	Annual Premium
Do these policies cover all companies listed in answer to question 1, 2, and 3? Yes No If No, provide details of all exceptions.
Limit of Liability
Limit of Umbrella Liability Coverage desired:	Amount of self-retention:	Policy Term:

Coverage on Underlying Policies
Do the underlying policies afford the following additional coverages? Provide details of sub-limits and deductibles, if any.
Coverage	Yes/ No	Sub-limit	Deductible	Coverage	Yes/ No	Sub-limit	Deductible
Advertising	Non-owned auto
Aviation Liability	Pollution Liability
Blanket Contractual	Products/ completed operations
Blasting, Pile-driving, Underpinning	Railroad Liability
Broad form P.D	Tenant’s Legal Liability
Care custody and control	Underground hazards
Employee benefits liability	Vendor’s Liability
Employee Liability	Watercraft Liability
Fire-fighting expenses	World-wide coverage
Liquor liability	Wrongful Dismissal
Mental Anguish	Others- Specify
If ‘Yes’ to any of the items, describe the coverage provided:
Is coverage given beyond that used in IBC standard form, Yes No If yes, what is the nature of special coverage? If manuscript liability policy, attach copy: additional insureds, etc.
Give details of any exclusions or restriction in coverage other than those printed in the form itself: personal injury, blasting, etc. Attach copy.
Does the primary Commercial General Liability exclude punitive damages or restrict coverage to compensatory damages? Yes No
Products/ Completed Operations
Describe products manufactured, sold, handled, or distributed and give estimated annual sales for each class (Record separately all aviations, automotive or marine products.) Products or related group or products (attach brochure).
Have any products been discontinued or recalled during the last 5 months? Yes No
If a completed operations exposure exists, describe below: ex: installation..
Contractual Liability
Describe contractual liability assumed at present. Attach copies of applications’ standard contract(s), if any, other than the following types of written agreements: lease of premises, easement agreement, agreement required by municipal ordinance, railway sidetrack agreement or elevator and escalator maintenance agreement.
Protective Liability
Are independent contractors employed? Yes No If yes, provide full details of work performed and state annual cost of work performed by contractors.
Do underlying policies listed in the schedule of Underlying Policies cover these exposures? Yes No If no, explain:
Are certificates of insurance requested from independent contractors? Yes No If yes, what limit:
Tenants Legal Liability
List all premises occupied but not owned by the applicant. If more room required, attach page. Indicate if none: None
Location	Occupancy	% Occupied	Estimated value of % Occupied	Tenants legal liability limit	Limited Form	Broad Form
Is lessor held harmless by applicant for damages to premises? Yes No If yes, to what extent?
Is TLL limit included in the occurrence and aggregate limit? Yes No
List all property of others in the care, custody or control of the applicant (include such property as data processing equipment, leased automobile, leased watercraft, leased machinery, materials on consignment, property stored, etc., together with its estimated value indicate if none.
Description of Property	Value	Type of Policy	Limit	Insurer
Automobile Liability
Does the applicant require excess coverage? Yes No If yes, provide answers to the following questions:
Provide the number of vehicles and indicate whether the applicant is the owner (O) or if the vehicle is leased (L)
Vehicles	#	O or L	Vehicles	#	O or L
Private Passenger	Trucks- heavy (over 11,341 kgs)
Vans, pick-up	Trucks- any used as courier service? Yes No
Snowmobiles/ Motorcycles	Tractor
Buses- van type (# seats: )	Trailer Units
Buses- school/ other(# seats: )	Tankers
Trucks- light (less than 4,535 kgs)	Emergency Vehicles- fire, police, etc
Trucks- medium (from 4,535-11,340 kgs)	Other
List any dangerous substances carried (including but not limited to explosives, munitions, corrosives, petroleum gases, gasoline, fuel oil, butane, propane, radioactive materials, PCBs) and give full details.
Are there any vehicles travelling to the USA? Yes No If yes, provide full details, (ie: type, number of vehicles, distance, frequency of trips, ect.)
Are any long haul operations over 100 km? Yes No If yes, provide full details (ie: type, number of vehicles, distance, frequency of trips, etc.)
Are any vehicles indicated in (a) permanently located outside the province? Yes No If yes, provide full details.
Are all owned or leased vehicles covered under the automobile policies listed in the Schedule of Underlying Policies? Yes No If no, explain.
Alternative fuel: Is any vehicle described above powered by other than gasoline or diesel fuel? Yes No If yes, state which vehicle(s), fuel used and type of installation (factory or conversion).
What percentage of drivers are less than 25 years of age?
Non-Owned Automobile
Does the underlying policy provide non-owned automobile coverage? Yes No
State estimated cost if hired, if any $
Current policy limit $
Errors and Omissions/ Professional Liability
Does the applicant operate a hospital, clinic, or first aid facility? Yes No If yes, describe facility
Does the applicant provide any consulting, inspection or other professional services to others for a fee? Yes No
Do policies listed in the Schedule of Underlying Policies cover this exposure? Yes No
Watercraft Liability
Describe fully any watercraft including type, length of craft and size of engine/ motors. State whether owned, non-owned, leased or chartered by applicant.
Provide details of rental operations, if any.
Does the applicant maintain a waterfront facility? Yes No If yes, provide details
Do policies listed in the Schedule of Underlying Policies cover these exposures? Yes No If no, explain
Aviation Liability
Indicate number and type of aircrafts including make, model, number of engines, seating capacity and whether owned, non-owned, leased or chartered by applicant.
Do any employees fly their owned or other aircraft on applicant’s business? Yes No If yes, how many?
Does the applicant expect to own, lease or charter aircraft within the next 12 months? Yes No If yes, provide full details.
Do policies listed in the Schedule of Underlying Policies cover these exposures? Yes No If yes, is passenger liability included? Yes No
Is the aircraft used for other than non-commercial transporting of passengers? Yes No If yes, provide details.
Does the applicant own or maintain a landing strip or hangar facilities? Yes No
Employers Liability
Are all employees in Canada covered by Workers’ Compensation? Yes No If no, state exceptions.
Are any employees located outside Canada? Yes No If yes provide full details.
Do policies listed in the Schedule of Underlying Policies cover Employers Liability for all employees not covered by workers Compensation? Yes No If no state exceptions.
Advertising Liability
Describe all radio, television and publishing activities contemplated for the next 12 months.
Are any unusual activities such as contests, exhibitions, etc. contemplated? Yes No If yes, describe.
Estimated annual expenditure: Applicant: $ Advertising Agency: $ Other: $
Do policies listed in the Schedule of Underlying Policies cover these exposures? Yes No Limit $
If the applicant is under contract with an advertising agency, has the agency’s policy been endorsed to include the additional interest of the applicant? Yes No If yes, to what extent?
Describe any social or sporting events sponsored by the applicant.
Atomic Energy Liability
Does the applicant’s operation involve the use of radioisotopes or any other radioactive materials? Yes No If yes, to what extent?
Do policies listed in the Schedule of Underlying Policies cover these exposures? Yes No
Is applicant engaged in any activity related to nuclear energy or defence? Yes No
Railroad Liability
Does the applicant operate an industrial railroad? Yes No If yes, describe fully, providing length of track, types and number of grade crossings and protection, average number of non-owned rollignstock handled per week.
Do locomotives owned by the applicant ever operate on the mainline of the railroad? Yes No If yes, describe fully.
Do policies listed in the Schedule of Underlying Policies cover these exposures? Yes No If no, state exceptions.
Claims
List all claims paid or outstanding (whether or not insured) during the last 5 years. List also any circumstances that may give rise to a claim.
Coverage	Date and Description of Claim	Total Paid ($)	Value Outstanding	# of claimants
Previous Policy History
Does the applicant currently carry, or have they ever held, Excess or Umbrella Liability Insurance? Yes No If yes, provide the following:
Policy #	Insurer	Policy Period	Limit	Retained Limit (S.I.R)	Annual Premium
Has any insurer rejected, cancelled or refused renewal of any umbrella Excess coverage? Yes No If yes, provide full details.

Applicant	Signature and Title	Date
Broker	Signature	Date