Frank Cowan Company Limited
75 Main Street North, Princeton, ON N0J 1V0
Phone: 519-458-4331 Fax: 519-458-4366
Toll Free: 1-800-265-4000
www.frankcowan.com
SPECIALTY PROGRAMS AND ASSOCIATION
GENERAL APPLICATION
GENERAL INFORMATION
Legal Name of Applicant
Mailing Address
Postal Code
Phone
Fax
Email
Website
Brokerage Name
Brokerage Address
Postal Code
Phone
Email
APPLICANT’S OPERATIONS (Give full description including: activities, programs, events, U.S. or international exposures)
OPERATIONS INFORMATION
How long has the Applicant been in operation?
This Applicant is classified as
For Profit
Not-For-Profit
This Applicant is
Sole Proprietor
Partnership
Corporation
Unincorporated (Other)
Date of incorporation
INSURANCE HISTORY
Current Insurer
Expiring Premium
Expiry Date
Target Premium
Is the current insurer offering renewal terms?
YES
NO
Are there any coverage restrictions being imposed by the present insurer?
LOSS/CLAIMS INFORMATION
Please describe any allegations; claims; or losses (including those relating to Abuse or Professional Negligence) in the past 5 years
including those without payment
Year
Type of Claim
Amount Paid
Are you currently aware of any circumstances which may reasonably be expected to give rise to a claim
that would be covered under any section of our policy?
Reserve for Unpaid Claim
YES
NO
Note that failure to provide information about any such circumstance may void coverage.
If "Yes", provide details.
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Name of the Regulatory body or legislation which oversees the Applicant’s Operation
List all Associations the entity belongs to
Does the Insured have any subsidiary or affiliated entities?
YES
NO
If "Yes", please provide details
LIABILITY COVERAGES (OCCURRENCE FORM)
Liability Limit Requested
$
Tenant’s Legal Liability Limit Requested $
Non-Owned Auto Limit Requested
$
Deductible Requested
$
LIABILITY INFORMATION
Number of employees: Full Time
Part Time
Number of volunteers
If An Association - Number of members
Annual Payroll (Including Benefits)
Is Insured covered under Provincial Workman's Compensation Plan?
Annual Revenue
YES
NO
Identify and provide numbers of Professional Employees by category, and indicate whether they are full-time or part-time (ie: Nurses, Social
Workers, Counsellors, Child and Youth Workers etc.)
Category
# of Full-Time
# of Part-Time
Describe all Fundraising events and show applicable receipts including liquor receipts where Insured holds Liquor License
Are any of the facilities rented to third parties?
If "Yes", do you get proof of Insurance?
Do Any Non-Medical Staff Administer Medication?
If "Yes", please describe
YES
YES
YES
NO
NO
NO
ABUSE
Is Abuse Liability Required?
Current Abuse coverage is
Occurrence
YES
NO
YES
NO
Claims Made
If Claims Made, what is the retroactive date required?
Abuse Liability Limit Requested
$
Are police records checked on all prospective employees and volunteers at least once every 3 years?
Please Note: Receipt and approval of an acceptable Abuse Protocol is required prior to binding.
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Frank Cowan Company
ERRORS & OMISSIONS LIABILITY – Claims Made Form
Is Errors & Omissions coverage required?
Limit Requested
$
YES
NO
Retro-active Date:
DIRECTORS' & OFFICERS'
Is coverage required?
YES
NO
# of Board Members
Annual Budget
$
FINANCIAL INFORMATION
This financial information must be furnished with respect to each Entity and each Benefit Program to be named in Item 1 of the policy
DECLARATIONS. For the most recent fiscal year-end provide the following consolidated financial information:
a)
Total Assets:
$
b)
Total Liabilities:
$
c)
Total Revenues:
$
d)
Net Income:
$
For the current fiscal year, please indicate:
i)
Estimated Revenue
ii)
Estimated surplus/deficit
Binding subject to completed Not for Profit Directors' & Officers' Liability Application
CRIME COVERAGES
Is this coverage required?
YES
Employee Dishonesty Form A, Commercial Blanket Bond Limit
$
Number of employees that handle Money-Securities etc. (Class A):
Computer & Transfer Fraud Limit:
$
Credit Card Forgery Limit:
$
NO
Broad Form Money & Securities – Loss Inside/Outside Premises Limit:
All Other employees:
$
Limits Over $ 100,000. Require Completion of Crime Supplement
LEGAL EXPENSE COVERAGE
Legal Defence Costs Limit Required
$
Additional Information:
Provide full details of any lawsuits in the past five (5) years with respect to any Board Member, Director, Officer, Employee, Volunteer or
Manager.
CYBER RISK INSURANCE
Is this coverage required?
YES
NO
YES
NO
If "Yes", complete Cyber Risk Insurance Short Form Application
ENVIRONMENTAL LIABILITY
Is coverage required?
Please fully describe exposure
Additional Supplements may be required.
BOARD MEMBER ACCIDENT
Is coverage required?
YES
NO
Limit Requested
$
Number of Board Members
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Frank Cowan Company
PROPERTY COVERAGES
Note: Provide FULL REPLACEMENT COST VALUES ON A PER LOCATION BASIS as our program does not
have co-insurance clauses or stated amount clauses
Note: A SITE PLAN including distances, is required for all buildings or locations situated within 150 feet of each other
Please complete Additional Property Supplemental Forms for Additional Locations – Available on our Website
Location address
Building Construction – Please indicate percentage for each type of construction
Fire Resistive (Concrete Walls; Roof; Floors)
%
Masonry Non-Combustible (Masonry walls; steel deck roof; concrete floors)
%
Non-combustible (steel on steel)
%
Masonry (Masonry walls; wood floors; wood roof)
%
All other (including Brick Veneer and Frame)
%
Occupancy by Insured
Occupied by Others as
Year Built
Year Updated: Plumbing
Heating
Number of stories
Total area of building (including basement)
Wiring
Roof
Is the building 100% sprinklered and centrally monitored?
YES
NO
Is the building 100% alarmed and centrally monitored?
YES
NO
YES
NO
What type of alarm?
Smoke
Heat
Intrusion
Distance to Fire Hydrant
Heating System
Distance to Fire Hall
Forced Air
Hot Water
Steam
Gas
Electric
Oil
Fuel Type
Wood
Describe secondary heating system (if applicable)
Asbestos: The following questions are applicable to all buildings built prior to 1980
Do any of the buildings that you own contain asbestos or asbestos products?
If "Yes"- Please provide full details as to whether or not buildings have been surveyed for both friable and non-friable asbestos materials
indicating the building, location, date surveyed and completed findings.
If "No"- has this been confirmed by a building survey?
Deductible requested
NO
$
Building Limit
Building is
YES
$
Owned
If more than one building, provide PER building
Leased
If leased, a copy of the lease agreement is required
Tenants Improvements Limit
$
Outdoor Equipment (including playground, fencing and signs) Limit
$
Contents (including equipment and furniture) Limit
$
Extra Expense Limit
$
Additional coverages required (e.g. Flood, Earthquake, Fine Arts, etc.)
Are there additional buildings or locations?
YES
NO
YES
NO
Have you included all location and values that are owned, leased, rented or under the control of the
Insured?
If "No", please explain
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Frank Cowan Company
DATA PROCESSING INSURANCE (Per Location)
Equipment/Hardware Limit
$
Laptops
$
Media Limit
$
Extra Expense
$
BUSINESS INTERRUPTION COVERAGES
Form Requested
Limit Requested
$
WORKPLACE DISRUPTION COVERAGE requested?
Limit Requested
YES
NO
YES
NO
YES
NO
$
Number of Locations owned and/or occupied by the Insured:
If "Yes", has any location ever been closed for infectious disease, contagion, food poisoning or vermin
infestation in the past 5 years?
If "Yes", please provide details
CRISIS MANAGEMENT COVERAGE requested?
Limit Requested
$
Please confirm in the past year the Named Insured (or any of their directors or officers) in relation to the Named Insured’s operations has not:
Defaulted on any debt obligation; Filed for bankruptcy reorganization under the bankruptcy and Insolvency Act of Canada; Been
criminally charged under the Criminal Code of Canada; Had allegations with respect to bodily injury or death to or sexually abused any
person in the performance of his or her duties; Experienced a withdrawal or demand for return of any grant, contribution or bequest in
excess of one hundred thousand dollars ($100,000); Had commencement of or threat of litigation or other proceedings by any
governmental or regulatory agency;
If "Yes", please explain
EQUIPMENT BREAKDOWN INSURANCE
Is cover required?
Please confirm Replacement Value of all Electronic Equipment
YES
NO
$
If any single piece of equipment over $ 100,000., please describe.
Contact Name and Phone Number if different from page 1
Name
Phone Number
Any additional comments or coverages required
The Applicant acknowledges that the information contained herein and in any supplemental applications or forms required
is true, accurate and complete, and that no material facts have been supressed or misstated. The Applicant acknowledges
a continuing obligation to report to the Insurer as soon as practicable any material changes in all such information, after
signing the application and acknowledges that the Insurer shall have the right to withdraw or modify any outstanding
quotations and/or agreement to bind the insurance based upon such changes. If a policy is issued, the insurer will have relied
upon, as representations, this application, any supplemental applications, and any other statements furnished to the Insurer in
conjunction with the risk to be insured.
The undersigned, on behalf of the insured organization, acknowledges that any personal information provided in connection
with this application (including but not limited to the information contained in this form) has been collected in accordance with
applicable privacy legislation and this information shall only be used or shared by the Company to assess, underwrite and
price insurance products and related services, administer and service insurance policies, evaluate and investigate claims,
detect and prevent fraud, analyze and audit business results and/or comply with regulatory or legal requirements.
Date
Title/Position
Signature
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Frank Cowan Company
COMMUNITY LIVING SUPPLEMENTAL FORM
List all Associations the Applicant belongs to and criteria for membership.
Has membership or registration ever been suspended, withdrawn, amended, declined or had
conditions attached?
If yes, please explain.
YES
NO
Has the Applicant ever been declined, non-renewed or cancelled by any insurer?
YES
NO
If yes, please explain.
Current Liability coverage is:
Occurrence
Current Liability Insurer:
Expiry Date:
Current Professional/Malpractice coverage is:
Current Professional/Malpractice Insurer:
Expiry Date:
If Claims-Made indicate Retro Active Date Required:
Claims-Made
Expiring Premium:
$
Occurrence
Expiring Premium:
Claims-Made
$
Number of Residents in Group Homes
Number of Supported Independent Living Residents
Are all professionals licensed/certified to practice in the province?
YES
NO
Do all qualified medical staff, including any interns, residents and fellows have CMPA
coverage?
YES
NO
If yes, do you obtain proof of CMPA coverage?
YES
NO
Do any professional staff have liability/professional insurance coverage elsewhere?
If yes, please explain.
YES
NO
Does the applicant comply with all provincial guidelines with respect to:
Needle stick injuries
Safe handling, collection & disposal of dressings, waste, blood/blood products and sharps
Patient lifting/moving
Infectious disease prevention & control
If no, please explain.
YES
NO
Is Associate Family Homes cover required?
If yes, please describe fully and attach copy of Agreement.
YES
NO
If no, please explain
How are qualifications of professional staff checked?
If no, please describe alternative insurance arrangements and for whom those arrangements apply.
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Frank Cowan Company