mpi liability insurance program...mpi insurance program application page (08 02 16) 1of 6 lms...

MPI Insurance P rogramApp l i ca t ion (08 02 16 ) Page1of6

LMSPROLINKLtd.|480UniversityAve.Suite800TorontoON.M5G1V2|TF:18006636828|F:18775951649|E:[email protected]

MPILIABILITYINSURANCEPROGRAMNewBusinessApplicationincludingOfficeProperty

SECTION1: APPLICANT INFORMATION 1. NameofApplicant:

2. MPIMembershipNumber:

3. FormofBusiness:¨ Individual¨ IncorporatedOrganization¨ PartnershiporJointVenture¨ Sole

Proprietorship4. Pleaseprovidethefollowingcontactdetails:

MailingAddress: City: Province: PostalCode: Phone: Fax: Email: Website:

5. Pleasedescribethenatureofyourbusiness(i.e.sourcesofrevenue):

6. Ifyouhaveothersubsidiariesorholdingcompaniespleaselisttheseentitiesanddescribeoperationsofeach:

7. Pleaseindicatethetypesofclientsserved: Professional&BusinessAssociations: ❏YES❏NO

Civic&PublicInterestOrganizations: ❏YES❏NO

OtherNot-for-ProfitOrganizations: ❏YES❏NO

OtherTypesofClients(ifapplicable): ❏YES❏NO

8. Ifyouplanormanageeventsfornon-profitorganizationsorprivateindividuals/families ❏YES❏NOdoyoureceiveconfirmationthattheymaintainaminimumof$1,000,000ofCommercialGeneralLiabilityinsurancetocovertheevent?If“NO”,pleaseexplainwhy:

9. Doyouplanormanageconsumer-focusedevents(e.g.,autoortravelshows) ❏YES❏NOwherethepublicpaysafeetoattend? If“YES”,pleaselisttheevents:

10. Pleaseprovidethenumberofemployeesworkingatyourfirm:

11. Pleaseprovidethetotalpayrollforthelast12months:



12. Pleaseprovidegrossfeesandrevenuesfromoperations/servicesprovided:

a. TotalAnnualGrossRevenues: Lastfiscalyear-end: $

Currentfiscalyear(projected): $

Revenuederivedfromclientsdomiciledin:Canada:_______%UnitedStates:_______%International:_______%

b. PleaseindicatethepercentageofrevenuesthatareFlow-ThroughRevenues: %(Flow-ThroughRevenuesarerevenuespaidtoyoubyyourclient,whicharethenusedtodirectlypaythirdpartysupplierssuchasvenues,hotels,caterers,transportationproviders,etc.)

13. PleaseindicatethepercentageofservicesyouphysicallyperformoutsideofCanada: %

14. PleasedescribeindetailyourU.S.operations(locationsserved,specifictypesofservicesprovided):

15. DoyoumaintainaphysicalofficeintheUSoroutsideofNorthAmerica? ❏YES❏NO16. Describethetypicalservicesprovidedbyyoursubcontractors(caterers,décor,etc.):

17. Doyoureceiveconfirmationfromthefollowingevent/meetingsuppliers/subcontractorsthattheymaintainaminimumof$1,000,000CommercialGeneralLiabilityinsurance?

Caterers: ❏YES❏NO BusTransportCompanies: ❏YES❏NO

AV,Lighting: ❏YES❏NO Stage,SeatingorSetInstallers: ❏YES❏NO

Decorators: ❏YES❏NO Entertainment: ❏YES❏NO

If“NO”,pleaseexplainwhy:

18. Doyouprovideanymeetingoreventservicesinadditiontoplanning, ❏YES❏NOmanagingandarranging(i.e.partyrentals,decorating,etc.)?

If“YES”,pleaseexplainwhy:

19. Inthepast,hastheApplicantoranyofhis/herpartners,officers,employeesorsubsidiaries ❏YES❏NO

everbeentherecipientofanyallegationsofprofessionalnegligenceinwritingorverballywhichmayreasonablygiverisetoaclaim?If“YES”,pleaseattachdetails.

20. IstheApplicantoranyofhis/heremployeesawareoffacts,circumstances,orsituations ❏YES❏NOthatmayreasonablygiverisetoaclaim,otherthanadvisedabove?If“YES”,pleaseattachdetails.

21. Pleasecompletethefollowingtablebasedonyourexistinginsurance: ¨ NOTAPPLICABLE



CurrentCommercialGeneralLiabilityPolicy CurrentErrors&OmissionsLiabilityPolicy

NameofInsurer: NameofInsurer: PolicyNumber: PolicyNumber:

Limit: Limit: Deductible: Deductible: ExpiryDate: ExpiryDate: Premium: Premium:

Claims: Claims:

SECTION2: OFFICEPROPERTY INSURANCEAPPLICATION

PleaseonlycompletethefollowingquestionsunderSection2ifyouareseekinganOfficePropertyInsurancequotationinadditiontoaquotationforinsuringyourbusinessoperations.

22. PleaseIndicateifadditionallimitsarerequired:

Coverage StandardProgramLimits IndicateifAdditionalLimitsareRequired

OfficeContents1: $50,000

ComputerEquipment,DataandMedia: $25,000

Laptop: Notautomaticallyincluded.$1.60/$100ofcoverage

BusinessInterruption:ExtraExpenses

$25,000

BusinessInterruption:ContingentBusinessInterruption $25,000

ComprehensiveCrime: $10,000

1OfficeContentsincludesFurniture,Fixtures,Stock,Supplies,TenantImprovements,etc.

23. Pleaseprovidethefollowingdetailsforyourofficelocation: YearBuilt:

Ifbuildingisover30years,hasitbeenfullygutted/renovatedinthelast10years? ❏YES❏NO

If“YES”,providedatesofupdatesforthefollowing:

Plumbing: Wiring: Roofing: Furnace: Heating:

Ifotherupdatesorrenovationshavebeendone,pleaseprovidefulldetailsonanothersheet.

Isthebuildinginastripmall? ❏YES❏NO Isthisanenclosedmall? ❏YES❏NO

Isthisastand-alonebuilding? ❏YES❏NO Areyouthesoleoccupant? ❏YES❏NOPleaseprovidethefollowingdetailsforyourofficelocation:

Yearbuilt: Squarefeetyouoccupy(yourunit):

Numberofunitsinbuilding: Numberofstoriesinbuilding:

Isthebuildingequippedwithsprinklers?❏YES❏NO Hydrantprotected? ❏YES❏NO



Doesithavesmokedetectors?❏YES❏NO If“YES”howmany?

Heatdetectors? ❏YES❏NO If“YES”howmany?

Distancetohydrant? Distancetonearestfirehall?

DoyouhaveanApprovedULCCentralStationBurglarAlarmSystem? ❏YES❏NO

If“YES”,pleaseprovidenameofmonitoringcompany DoyouhaveanApprovedULCCentralStationFireAlarmSystem? ❏YES❏NO

If“YES”,pleaseprovidenameofmonitoringcompany Describeanyphysicalbarrierstoentry:(Forexample:doors,locks,bars,etc.)

BuildingConstructionDetails–Pleasecheckoneofthefollowing:

❏ Class1: FireResistiveIncludeswalls,floorsandroofofmasonry,reinforcedconcreteorothernon-combustiblematerialwithhighfireresistiverating.Nostructuralsteelunlesssteelprotectedbystandardthicknessoffireresistiveinsulation.

❏ Class2: Non-CombustiblewithMasonryWalls

Includesbuildingswithsteeldeckroofand/orotherunprotectedstructuralsteel.

❏ Class3: Non-CombustiblewithNon-MasonryWalls

Includessteelonsteelbuildings,asbestoscladbuildingswithsteelframe.

❏ Class4: Masonry Brick,stone,concreteblockorhollowtilewallswithwoodjoistroof.Thisclassincludesmilltypeconstruction.

❏ Class5: MasonryVeneer Framebuildingwithbrickveneer,stoneorothermasonryveneer.

❏ Class6: Frameandallother Includesroughcast,metalclad,forexample.

ExistingInsuranceCompany(ifapplicable): ExpirationDate: ExpiringPremium: ProfessionalLiability(E&O)RetroactiveDate(ifapplicable): Haveyoueverhadprofessionalinsurancecancelledordeclined? ❏YES❏NO

If“YES”,pleaseprovidethefollowinginformation:Whichinsurancecompany? When? Forwhatreason?



FiveYearLossHistoryforLiabilityand/orOfficeProperty:

Date(DD/MM/YY) Type AmountPaid AmountO/S Details

NameandaddressofanyMortgagees/Lienholders:

SECTION3: REQUESTEDL IABIL ITY INSURANCEL IMITS

Pleaseselectthecoveragelimitsthatyouwouldlikeaquotationfor:

ProfessionalLiabilityErrors&Omissions

CommercialGeneralLiability

¨ $500,000

¨ $1,000,000 ¨ $1,000,000

¨ $2,000,000 ¨ $2,000,000

¨ $3,000,000 ¨ $3,000,000

¨ $4,000,000 ¨ $4,000,000

¨ $5,000,000 ¨ $5,000,000



IMPORTANTNOTICETOAPPLICANT:

Thisisanapplicationforinsuranceandtheinsurerisnotobligatedtoaccepttheapplicantforcoverage.Ifapolicyisissued,onesignedcopyoftheapplicationwillbeattachedtothepolicyorcertificate.Signatureontheapplicationformandsubmissionofapremiumpaymentdoesnotbindtheinsurertocompleteaninsurancetransactionwiththeapplicant.Thispolicy provides Errors andOmissions insurance that applies on a claims-madebasis. The following provides a general description of this coverage and is subject to the terms andprovisionsoftheactualpolicy.

A. ThepolicywillnotcoveranylossesfromincidentswhichtakeplacebeforetheRetroactiveDate,ifany,oraftertheexpirationofthepolicyperiod(subjecttotheExtendedReportingPeriodprovision).

B. ThepolicywillprovidecoverageforlossesfromincidentswhichtakeplaceonoraftertheRetroactiveDate,ifany,butbeforethebeginningofthepolicyperiodonlyiftheinsureddidnotknowoftheincidentbeforethebeginningofthepolicyperiod.

C. Thepolicywillnotcoveranylossforwhichaclaimisfirstmadeafter:1. Theexpirationofthepolicyperiodoritsearlierterminationdate,ifany;or2. TheExtendedReportingPeriodifanyandthenonlyinaccordancewiththetermsdescribedinthepolicy.

D. Thepolicywillonlycoverclaimswhicharefirstmade:1. Duringthepolicyperiod;or2. DuringanExtendedReportingPeriodifanyandthenonlyinaccordancewiththeterms

andconditionsdescribedintheExtendedReportingPeriodSectionofthepolicy.E. PleaserequestacopyofthePolicyandreviewthetermsandconditionstoobtainmoreinformation.F. ThelimitsforDefenceCostsareoverandabovetheliabilityandwillnotreducethelimitofliability.

DisclosureandConsent:

AspartofmyapplicationforinsuranceIconsenttothecollectionanduseofpersonalinformationrequiredforthepurposesofconsideringmyapplicationforinsurancebytheinsurerandtheauthorizedinsurancebrokerforOntarioApplicants,LMSPROLINKLtd.,and/ortheauthorizedinsurancebrokerforapplicantsoutsideofOntario,ThePROLINKInsuranceGroupInc.theinsurerandthebrokerareauthorizedtocollect,use,anddisclosepersonalinformationandprovidesuchpersonalinformationtothirdparties,asrequiredforthepurposeofunderwritingthisapplicationforinsurance,aspermittedbytherelevantprovincialandfederalprivacylawsorotherapplicablelaws,andasrequiredbytheapplicant’sassociationand/orgoverningbody.IunderstandthatatanytimeImayasktoreviewthepersonalinformationpertainingtomyapplicationforinsuranceandtheinsurerandbrokerwillbeobligatedtoprovidemewithanyinformationIamentitledtoreceiveundertherelevantprovincialandfederalprivacylawsorotherapplicablelaws.IhavereviewedtheinformationinthisApplication,gatheredinformationfromallpartners/directors/officers/employees/agentsunderthisentitywhetherpresentorpriorregardingtheirknowledgeorawarenessofanyclaimsorsituationswhichmaygiverisetoanyclaims.TheClaimInformationForms,ifany,thatareattachedtothisApplicationincludethedetailsof:

A. Allfacts,situations,andincidentswhichhaveoccurredinthepastandwhichmayreasonablybeexpectedtoresultinaclaim,suitorarbitrationagainstus(theApplicant);

B. Allfacts,situations,andincidentswhichhaveoccurredinthepastandwhichmayreasonablybeexpectedtoresultinaclaim,suitorarbitrationagainstus(theapplicant)inthefuture.Allsuchclaims,suitsandincidentshavebeenreportedtoour(Applicants)currentorpriorinsurer(s).Itisunderstoodandagreedthatallsuchclaims,suits,arbitrations,factsituationsandincidentswillbeexcludedfromcoverageunderanypolicyissuedbytheinsurer.

It isunderstoodandagreedthatfailuretoprovidetrueandcompleteresponsetoanyofthequestions,statementsorrequestfor informationinthisApplicationortoprovideanyotherinformationmaterialtothisApplicationmay,atthesoleoptionoftheinsurer,resultinthevoidingoftheinsurancepolicyissuedinrelianceonthisApplicationand/ordenialofcoverageforspecificclaimsassertedagainstus(theApplicant)oranyotherinsuredunderthepolicy.TheundersignedonbehalfoftheApplicantandallotherinsuredsunderthispolicyissuedbytheinsurer, herebywaives anydefense to an actionby the insurer for voidingor revokingof thepolicybaseduponmisrepresentationof fact or failure todisclosematerial information inconnectionwiththisApplication.TheApplicantagreestoholdtheinsurerharmlessfromalllossasaresultofanysuchmisrepresentationorfailuretodisclose,including,withoutlimitation,allcostsandattorneyfeesincurredbytheinsurerinconnectionwithsaidactionforvoidingorrevokingthepolicy.IHEREBYDECLAREthattheabovestatementsandparticularsaretruetothebestofmyknowledge,thatIhavenotsuppressedormisstatedanyfactsandIagreethatthisapplicationshallformpartoftheinsurancepolicy.IalsoacknowledgethatIamobligatedtoreportanychangesthatcouldaffectthedisclosuresinthisapplicationthatoccurafterthedateofsignature,butpriortotheeffectivedateofcoverage.

Applicant’sSignature:________________Name(pleaseprint):_________________Date:_______________

PLEASECOMPLETEANDRETURNTHEAPPLICATIONTHROUGHONEOFTHEFOLLOWINGMETHODS:ü V ia EMAIL p lease send to : [email protected] ü V ia FAX p lease send to : 416 595 1649 a t tn . MPI PROGRAMMANAGER ü V ia MAIL p lease send to : LMS PROL INK L td . 480 Un ivers i ty Ave . Su i te 800 Toronto , ON. M5G1V2

mpi liability insurance program...mpi insurance program application page (08 02 16) 1of 6 lms...

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