Umbrella Insurance Application

UMBRELLA LIABILITY INSURANCE APPLICATION

1. GENERAL INFORMATION

1) Name of Organization or Legal Entity (Applicant) including any subsidiaries:

(please show complete name as you wish it to appear on the policy)

Company structure: Individual Corporation Partnership Other

2) Head Office Address (Not P.O. Box):

Other locations (please list and describe):

Website:

Please describe the Company’s operations:

Are any operations conducted outside of Canada? YES NO

If YES, please describe:

3) Number of years the Company has been in business:

4) What are your sales/revenues estimated for this year?
Canada: $    U.S.A.: $    Foreign: $

5. PRODUCTS AND/OR OPERATIONS

a) Describe products manufactured, sold, handled or distributed and give estimated annual sales for each product per country:

b) Have any products been discontinued and/or recalled in the past five (5) years? YES NO

If YES, please describe:

6) Are all Companies listed in question #1 to be covered by this insurance? YES NO

If NO, please explain:

7. SCHEDULE OF UNDERLYING INSURANCE

List all General Liability, Automobile Liability, Auto Garage Liability, Workers Compensation, Environmental Impairment Liability and all Property policies applicable to property of others in your care, custody or control:

8) Does the underlying CGL policy contain a "General Aggregate" limit for non product/completed operations losses? YES NO

Please list both the per occurrence limit and the General Aggregate limit:

9) Does your primary CGL policy cover the following exposures?

10) Does your policy have a sub-limit on any coverage? YES NO

If YES, please describe:

11) Is any coverage on the underlying subject to a deductible? YES NO

If YES, please describe:

12) Give details of any special or unusual exclusion/restriction in your primary policy:

13) Existing Umbrella Coverage: Insurer:   Limit:

Expiry Date:   Premium:

14) a) Limit of Umbrella Coverage desired: $

b) Does the Applicant now carry, or has the Applicant ever carried, excess liability insurance? YES NO

If YES, please give name of carrier and details of coverage, limits, premiums, etc.

15. AUTOMOBILE LIABILITY

a) State the number and type of owned and/or leased automobiles:

b) If any of the above are engaged in the following, state number and type:

i) Long Haul (over 100 miles) operations:

Operating into the U.S.:

ii) Transportation of hazardous commodities, gasoline and/or fuel oil:

c) Do underlying policies cover all these exposures? YES NO

If NO, please note exceptions:

16. WATERCRAFT LIABILITY

a) State the number, type and use and whether or not owned, leased or chartered watercraft:

b) Do underlying policies listed cover these exposures? YES NO

If NO, please specify:

17. RAILWAY LIABILITY

a) Does Applicant operate an industrial railway? YES NO

If YES, please give full details including length of track (in km), type quantity of rolling stock owned by Applicant, number of crossings, with warning devices used, and the average weekly quantity of non-owned rolling stocks:

b) Do locomotives owned by Applicant operate on a mainline of a railroad? YES NO

If YES, please describe in detail:

c) Do underlying policies listed cover these exposures? YES NO

If NO, please explain:

18. AVIATION LIABILITY

a) Does Applicant expect to own, lease or charter aircraft within the next twelve (12) months? YES NO

If YES, please give details:

b) Are there any of the Applicant’s products used in any type of aircraft? YES NO

19. ADVERTISING LIABILITY

a) Describe all radio, television and publishing activities contemplated for the next twelve (12) months.

b) To what extent do underlying policies listed cover these exposures?

20. EMPLOYER’S LIABILITY

a) Is Workers Compensation Insurance carried in all Provinces where the company operates? YES NO

If NO, please give description of employees not covered by Workers Compensation:

b) Do underlying policies cover Employer’s Liability in all those Provinces where Workers Compensation Insurance is not provided? YES NO

If NO, please note exceptions:

21. PREVIOUS LOSS EXPERIENCE

a) List all claims, insured or not, paid or reserved during the past five (5) years and state total amount of each claim:

22) Has any Insurer cancelled, or declined to renew any form of liability insurance for the Applicant? YES NO

If YES, please give details:

2. NOTICE CONCERNING PERSONAL INFORMATION

By purchasing insurance from Beazley Canada Limited, a customer provides Beazley with his or her consent to the collection, use and disclosure of personal information, including that previously collected, for the following purposes:

• the communication with underwriters;
• the underwriting of policies;
• the evaluation of claims;
• the detection and prevention of fraud;
• the analysis of business results;
• purposes required or authorized by law.

For the purposes identified above, personal information may be disclosed to Beazley’s related or affiliated companies and service providers.

Further information about Beazley’s personal information protection policy may be obtained by contacting their privacy officer at 416-601-2155.

3. WARRANTY STATEMENT

The undersigned warrants that to the best of their knowledge, the statements set forth in this Application are true. The undersigned also warrants that they have not suppressed or misstated any material fact.

If the information provided in this Application should change between the date of the Application and the effective date of the policy, the undersigned warrants that they will immediately report such changes to the Insurer.

Signing this Application does not bind the undersigned to purchase this insurance, nor does it bind the Insurer to issue this insurance. However, should the Insurer issue a policy, this Application shall serve as the basis of such policy and will be attached to and form part thereof.