Get a Business Liability Umbrella Quote

Section 1: Business Name & Address

Name of Insured (in full)

Street Address

City

Province

Postal Code

Name of Insurance Brokerage

Insurance Broker First Name

Insurance Broker Last Name

Insurance Broker Email Address

Section 2: Operations

Length of Time in Business

years

Full Description of All Operations

Are any operations conducted outside of Canada?

Yes

Please describe operations outside of Canada

Are all operations to be covered by this insurance?

Yes

Please provide details

Have any products been discontinued and/or recalled in the past 5 years?

Yes

Please provide discontinuation/recall details

Are all employees covered under Worker's Compensation?

Yes

Please state Worker's Compensation exceptions

Do underlying policies cover Employers' Liability?

Yes

Please state Employers' Liability exceptions

Section 3: Quote

What limit are your seeking quotation for?

Section 4: Financials

Receipts/Revenues Estimated for Current Year

Receipts/Revenues from Last Year

Receipts/Revenues from Previous to Last Year

Section 5: Automobiles

Do you operate automobiles?

Yes

Private Passengers

Light Trucks

Heavy Trucks

Tractors

Trailers

Buses

U.S. Vehicles

Total Annual km

Total Annual km (U.S.)

Are any long haul (over 200 km) operations involved?

Yes

Please state the number of vehicles/frequency and radius of operations

Are any hazardous goods (i.e. explosives/flammables) carried?

Yes

Please state the number of vehicles/frequency and radius of operations

Section 6: Aircraft

Do you operate aircraft?

Yes

Owned

Yes

Non Owned

Yes

Are aircraft chartered with crew?

Yes

Do insured directors/officers/employees pilot aircraft?

Yes

State who and pilot experience

Please describe the amount of usage time and distance flow

Do you have any plans to buy/lease/charter any aircraft in the next year?

Yes

Please describe plans

State number, location, type and size of any private air strips or fields

Section 7: Watercraft

Do you operate watercraft?

Yes

Please describe any owned or non-owned watercraft (i.e. size/usage)

Are any watercraft facilities operated by the Insured?

Yes

Please describe the facilities

Do underlying policies cover these exposures?

Yes

Section 8: Railroad

Do you operate a railroad?

Yes

Please describe railroad (length of track, number of crossings and how protected)

Do you have a sidetrack on your premises?

Yes

Is it in regular use?

Yes

Do underlying policies cover these exposures?

Yes

Section 9: Nuclear Liability

Do your operations involve the use of radioisotopes, or any other radioactive materials?

Yes

Please describe nuclear operations

Section 10: Contractual Liability

Please state any unusual contractual obligations which you have entered into , or any situation where you have agreed to assume another's obligations

Section 11: Protective Liability

Please describe any work (along with amounts) that will be performed by others for you during the coming year

Do you require proof of insurance from all Contractors & Suppliers?

Yes

What limit of liability do you require be provided?

Section 12: Claims History

Are you aware of any past event(s) that may lead to a loss or claim?

Yes

Are there any reported losses in the last 5 years?

Yes

List all known and reported third party losses for the past 5 years

Section 13: Underlying Insurance

List all policies that your are requesting to be scheduled on the Umbrella Policy

Section 14: Declarations

The information in this application form is true and correct and I/we have not withheld any relevant information.

I/We understand that any statement made in this application will be treated as a statement made by all of the people to be insured.

Section 15: Electronic Signature

Electronic Signature

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