CHUBB I NSURANCE CO M PANY O F CANADA
199 BAY STREET, SUITE 2500
P.O.BOX 139, COMMERCE COURT POSTAL STATION
TORONTO, ON
M5L 1E2
TELEPHONE: (416) 359.3222
FAX: (416) 359.3166
COMMERCIAL GENERAL LIABILITY & UMBRELLA APPLICATION
1. APPLICANT
a)
Name of applicant:
b)
Address of applicant:
Postal Code
c)
Applicant is:
Corporation
Individual
Partnership
Other
Description of operations:
d)
Year of incorporation:
Name and address of subsidiaries (domestic and foreign):
2. DETAILS OF REQUIRED COVERAGES
a)
Effective date of insurance:
b)
Name of present insurer:
c)
Has the insurer ever rejected or cancelled any insurance?
Yes
No
If yes, provide details.
Please provide the following documents:

Latest annual report.

Brochures or other relevant documentation concerning the products.

List of any other document attached to this application.
APPLICATION – Commercial General Liability/Umbrella
Page 1 of 9
3. BUILDINGS OR PREMISES
a) Describe all buildings owned or rented by applicant or its subsidiaries.
Occupancy
Construction
Address
Applicant
A.S.
Occupancy and distance of
nearby exposures
Other
b) Specify the percentage occupied (square footage) and annual rent of each building or premise listed above.
Address
Area occupied by the applicant
Area occupied by others
Annual rent
Does applicant have any interest as owner, lessee or tenant in the following?

Freight or passenger elevators
If yes, specify number, type, capacity, use and locations.
Yes
No

Lots
If yes, specify location, area, use and security measures.
Yes
No

or

Owned watercrafts
Yes
No
Leased or chartered watercrafts
If yes, specify number, type, length and H.P.
Yes
No

Leased aircraft
If yes, specify number and annual cost of leasing.
Yes
No
APPLICATION – Commercial General Liability/Umbrella
Page 2 of 9
4. OPERATIONS
Description of applicant’s operations and annual sales.
Annual sales
Description
b)
Last year annual sales
Specify the percentage of annual sales:

In Canada
%

in United States
%

Other countries
%
List the countries :
c)
Give amount of all products manufactured, sold or distributed by applicant IN CANADA or total estimated annual receipts of completed
operations.
Types of products or completed operations
d)
Amount
Description and origin of materials or principal components of these products :
APPLICATION – Commercial General Liability/Umbrella
Page 3 of 9
e)
Give amount of all products manufactured, sold or distributed by applicant OUTSIDE CANADA or total estimated annual receipts of
completed operations.
Amount
Types of products or completed operations
f)
Does the applicant deliver, install or service his products after sale?
If yes, specify the country:
Yes
No
Canada
United States
Other
Specify:
g)
Number of employees and annual payroll.
Number of employees
h)

Administration and clerical employees

Salesmen

Servicing

Others

TOTAL
Last year
Are the products labelled:
ULC
i)
Estimated annual payroll
CSA
ISO
Is there any quality control?
Other?
Yes
No
Spécifier/Specify:
j)
Applicant’s major customers or its biggest contracts:
APPLICATION – Commercial General Liability/Umbrella
Page 4 of 9
k)
Is the product a component of automobiles, watercraft, aircraft or trains?
Yes
No
Yes
No
Specify:
l)
Does the applicant handles any pollutant or hazardous material?
If yes, explain:
Specify quantities, methods of storage and handling, methods of transportation off-premises, allowances given to others to dispose of
waste on premises, type of supervision.
m) Does the applicant work under a “wrap up” policy?
Yes
No
Yes
No
If yes, explain:
n) Does the applicant do blasting, demolition, underpinning, pile-driving, shoring, logging or interior
welding activities?
If yes, explain:
o)
Give reason for discontinuing production and year. Specify annual sales.
p)
Are there any products or activities related to nuclear energy or defence?
Yes
No
q)
Do any products or activities imply usage of radio-isotopes or radioactivity?
Yes
No
Yes
No
Yes
No
5. INDEPENDENT CONTRACTORS
a)
Does the applicant employ subcontractors or independent contractors ?
If yes, give description and estimated annual cost.
b) Does the applicant require full proof of liability insurance?
If yes, what are the limits of insurance required?
c)
Has the applicant executed a hold harmless agreement with the subcontractor indemnifying him?
APPLICATION – Commercial General Liability/Umbrella
$
Yes
No
Page 5 of 9
6. INCIDENTAL MALPRACTICE LIABILITY
a)
Does the applicant operate a hospital, a clinic or a first aid facility ?
If yes:

Specify:

Number of doctor:

Number of nurses:
Full time
Yes
No
Yes
No
Part time
b)
Is individual liability of employed doctors and nurses covered by insurance?
If yes, what are the limits of insurance provided?
$
7. ADVERTISING
a)
Annual budget:
$
b)
Does the applicant use an advertising agency?
c)
Description of unusual advertising activities (contests, exhibits, etc):
Yes
No
Yes
No
Yes
No
8. CONTRACTUAL LIABILITY
Does the applicant assume any liability, by contract, verbal or written agreements?
If yes, please attach wording of such contract or written agreements.
9. AUTOMOBILES
a)
Number of automobiles owned by the applicant:
b)
Are there any non-owned vehicles?
If yes, give details on number and use.
c)
Number of non-owned automobiles:
d)
If a number is stated in b), give estimated annual cost of rented vehicles:
e)
Number of employees using their car for company business:
APPLICATION – Commercial General Liability/Umbrella
$
Page 6 of 9
f)
List number and type of owned and leased automobiles by the applicant. Include radius of operation.
Private passenger
Light commercial
Medium commercial
Heavy
Extra heavy
g)
Are vehicles used for long haul:
across Canada?
Yes
No
Yes
No
Yes
No
If yes, specify provinces.
in the United States?
If yes, specify which states.
Applicant’s products
If yes, specify:
Products of others
Both
h)
Are vehicles utilised in the transportation of flammable, caustic or explosive substances?
i)
Describe all losses paid or outstanding in amounts greater than $25,000during the past five years.
10 PREVIOUS LOSS EXPERIENCE
List all liability claims within the last five years, whether settled or not.
Bodily Injury
Property Damage
APPLICATION – Commercial General Liability/Umbrella
Date
Paid amount or reserve
Page 7 of 9
11. COVERAGE REQUIREMENTS
Limit of Insurance:
$
Comprehensive General Liability
Yes
No
Yes
Deductible $500 applicable on property damage
Broad form property damage
a)
Per claimant
Forest fire fighting expenses
b)
Per occurrence
Limit
Deductible
$
$
On occurrence basis
Non-owned automobile liability
On claims made basis
Broad form automobile endorsement
Protection mondiale
World-wide coverage-Suits brought within Canada & USA
Q.E.F. 94-Damage to hired automobiles  1 000$ Deductible
Employee benefits administration
Non-Owned watercraft
Limit per claim
Aggregate limit
Deductible
$
$
$
Non-owned aircraft
Contractor’s protective liability
Incidental malpractice liability (medical)
Blanket contractual liability
Garage liability
Products and completed operations
Pollution liability (hostile fire)
Contingent employer’s liability
Blasting endorsement
Voluntary medical payments
X.C.U. deletion endorsement
Per individual
Per accident
$
$
No
Advertising liability
Employees as named insureds
Independent vendors as additional insured’s, broad form
Tenant’s legal liability-Broad form * 1 000 000 $ Montant/Limit
Host liability
Personal injury
Voluntary workers as additional insureds
Cross liability
60 days canc. clause
Elevator liability
Other special endorsements
Elevator collision * 10 000 $ Limit
Specify :
Property damage on occurrence basis
Limit of Insurance:
$
APPLICATION – Commercial General Liability/Umbrella
Desired Umbrella limits
Page 8 of 9
12. SCHEDULE OF PRIMARY POLICIES
COVERAGE
CARRIER
POLICY TERM
LIMIT
PREMIUM
$
$
$
$
$
$
$
$
$
$
Yes
No
General Liability
Automobile
Professional
Directors and Officers
Others (aviation, marine, advertising)
Do these policies insure all corporations and subsidiaries of the applicant?
If not, explain :
The applicant certifies that the above statements and facts are true and that no information has been suppressed or misstated.
Date:
By:
Title:
APPLICATION – Commercial General Liability/Umbrella
Page 9 of 9