Contact Information

Full Name

Email *

Phone *

Name Of Applicant

Operating Name

Website

Address

Street Address

City

Postal code

Risk Location

Principal Onwer(s)

Insured is

Owner

Tennant

Landlords Name & Address

Occupancy By Others

Yes

No

If Yes, Details:

Loss Payee / Mortgage / Additional Insured (Indicate & Include address above)

Insurance Experience

Are You The Broker On Record?

Yes

No

If Yes, How Many Years Have You Been The Broker On Record?

Experience:

Current/Last Insurance:
Ex-Dates:
Current CGL Limit Offer:

Renewal Offered:

Yes

No

If Yes, Offer?

If No, Reason?

Full Insurance History

(At Least 5 Years With Full Operations)

Full Operations Experience:

Insurer:
Eff/Ex-Dates:
Coverage:

Experience Continued:

Insurer:
Eff/Ex-Dates:
Coverage:

Continued (Can Skip If Not Applicable)

Insurer:
Eff/Ex-Dates:
Coverage:

If This Is A New Owner For An Existing Business Please Advise Insurance History Of Prior Owner As Well:

Insurer:
Eff/Ex-Dates:
Coverage:

Have You Had Any Insurance Refused Or Cancelled Over The Last 7 Years?

Yes

No

If Yes, What Was The Reason?

List Of All Losses Or Claims

(Whether or not insured - Sustained during the past 7 years on all operations owned or operated or at location where managerial experience was gained)

Loss Experience:

Date Of Loss:
Details Of Loss:
Amount Paid/Reserve:
Open/Closed:

Loss Experience Continued:

Date Of Loss:
Details Of Loss:
Amount Paid/Reserve:
Open/Closed:

Loss Experience Continued: (can skip if not applicable)

Date Of Loss:
Details Of Loss:
Amount Paid/Reserve:
Open/Closed:

If Previous Losses Occured, What Steps Were Taken To Prevent Reoccurance?

New Venture Within The Last 7 Years?

Yes

No

If Yes, Prior Experience In The Hospitality Industry:

Prior Experiences:

Name Of Principal:
Name & Location Of Establishment:
As Owner/Operator Or Worked As Manager:
Dates:
Total Number Of Years:

Prior Experiences Continued:

Name Of Principal:
Name & Location Of Establishment:
As Owner/Operator Or Worked As Manager:
Dates:
Total Number Of Years:

Section 2 - Crime

Burglar Alarm:

Central Station Monitored

Local

None

Percentage Of Premesis Alarmed:

Monitoring Company:

Percentage Protected:

Dedicated Line:

Yes

No

Connected To Fire Detection:

Yes

No

CCTV In Place:

Yes

No

If Yes, Do You Retain Copies Of The Video For Future Use?

Number Of Cameras:

Inside:
Outside:

Metal Bars On All Windows & Doors?

Yes

No

Are Doors Fitted With Deadbolts?

Yes

No

Other Security Features:

Number Of Employees Handling Money:

Managers:
Staff:
Other:

Section 3 - Commercial General Liabillity

Lisenced Capacity:

Internal:
Patio:

Hours Of Operation:

From:
To:

Days Of Operations:

From:
To:

Liquor Sales:

Actual Revenue This Year:
Last Year:
Two Years Ago:
Projected Gross Receipts For The Coming Year:

Food Sales:

Actual Revenue This Year:
Last Year:
Two Years Ago:
Projected Gross Receipts For The Coming Year:

Hall Rental Receipts:

Actual Revenue This Year:
Last Year:
Two Years Ago:
Projected Gross Receipts For The Coming Year:

VLTs:

Actual Revenue This Year:
Last Year:
Two Years Ago:
Projected Gross Receipts For The Coming Year:

Cover:

Actual Revenue This Year:
Last Year:
Two Years Ago:
Projected Gross Receipts For The Coming Year:

Liquor Store:

Actual Revenue This Year:
Last Year:
Two Years Ago:
Projected Gross Receipts For The Coming Year:

Merchandise:

Actual Revenue This Year:
Last Year:
Two Years Ago:
Projected Gross Receipts For The Coming Year:

Other; Describe

Other:
Actual Revenue This Year:
Last Year:
Two Years Ago:
Projected Gross Receipts For The Coming Year:

Total Receipts:

Actual Revenue This Year:
Last Year:
Two Years Ago:
Projected Gross Receipts For The Coming Year:

Disc Jockey:

Yes
No
Nights/Week:
Type:

Live Bands:

Yes
No
Nights/Week:
Type:

Other Entertainment:

Yes
No
Nights/Week:
Type:

Karaoke:

Yes
No
Nights/Week:

Rave/All Age Events:

Yes
No
Nights/Week:

Burlesque or Drag Shows:

Yes
No
Nights/Week:
Type:

Exotic Dancers:

Yes
No
Nights/Week:

Comedy Club:

Yes
No
Nights/Week:

Cover Charge:

Yes
No
Nights/Week:

Happy Hour:

Yes
No
Average/Person:

Mechanical Amusement Devices:

Yes
No
Days:
Hours:

Including Mechanical Bulls:

Yes
No
How Many:

Do You Use Bubbles, Foam, Dry Ice:

Yes
No
Describe Procedure & Times Used:

Sporting Activities & Special Events:

Yes
No
If Yes, Please Describe:

Pyrotechnics/Special Lighting:

Yes

No

Describe In Detail:

Security: (If yes, provide details below)

Yes

No

Bouncers (Authorized to Forcibly Eject)

# Males:
# Females:
# Of Days:

Door Control (Check Indentification/Count Heads; No Authority To Eject):

# Males:
# Females:
# Of Days

If Bouncers Are Employed, Please Provide List Including:

Name Of Employed Bouncers:
Date Of Birth Or Age:
Years Of Experience (Whether Insured or elsewhere):
Security Registration # (In applicable provinces):
Confirm If Any Complaints Or Claims Ever Made Against The Individual:
Criminal Background Check Done & Clear:

Are Bouncers Sub Contracted?

Yes

No

If Yes, Is Proof Of Liabillity Insurance Obtained?

Yes

No

Has The Insured Had Any Food Or Health Violations?

Yes

No

Has The Liquor Permit Ever Been Revoked Or Suspended?

Yes

No

If Yes, Please Provide Some More Details

Please note that after completing this application, further details or risk management may be requested depending on your type of operation

Staffing At The Operation

Staff:

Number Of Employees:
Managers:
Full-Time:
Part-Time:

Is The Owner Involved In The Day-To-Day Management Of The Establishment:

Yes

No

If No, Please Provide More Details:

Have All Managers/Servers Taken The Provincial Server Program Or Equivalent, And Are New Employees Required To Take This Course Before Working?

Yes

No

If Yes, Please Clarify

Does The Establishment Have A Staff Training Program?

Yes

No

If Yes, Provide Further Details

Do You Maintain An Incident Log?

Yes

No

How Long Is The Log Kept For?

Who Maintains The Log?

Section 4 - Boiler Insurance / Mechanical Breakdown

Is This Coverage Required?

Yes

No

Coverage Will Follow Form To The Property Section

Limits Of Insurance

Property:

Buildings:

ACV:
RC:
Deductable:
Co-Ins:
Limit Insurance:

Contents Of Every Description:

ACV:
RC:
Deductible:
Co-Ins:
Limit Insurance:

Propery Extensions:

Yes
No (To follow if quoted)

Profits:

Deductibles:
Co-Ins:
Limit Insurance:

Ordinary Payroll:

Deductibles:
Co-Ins:
Limit Insurance:

Gross Earnings:

Deductibles:
Co-Ins:
Limit Insurance:

Rents Or Rental Value Form:

Deductibles:
Co-Ins:
Limit Insurance:

Sewer Back-up:

Deductibles:
Co-Ins:
Limit Insurance:

Earthquake - All Other Provinces:

Yes
No
Deductibles:
Co-Ins:
Limit Insurance:

Earrthquake - BC

Yes
No
Deductibles:
Co-Ins:
Limit Insurance:

Flood:

Yes
No
Deductibles:
Co-Ins:
Limit Insurance:

Mechanical Breakdown:

Yes
No
Deductibles:
Co-Ins:
Limit Insurance:

Other:

Other Name
Deductibles:
Co-ins:
Limit Insurance:

Other (Additional)

Other Name:
Deductibles:
Co-Ins:
Limit Insurance:

Crime:

Employee Dishonesty - Form A:

Deductibles:
Co-Ins:
Linit Insurance:

Money Orders & Counterfit Paper Currency Coverage:

Deductibles:
Co-Ins:
Linit Insurance:

Depositers Frogery Coverage:

Deductibles:
Co-Ins:
Limit Insurance:

Credit Card Forgery:

Deductibles:
Co-Ins:
Limit Insurance:

Interior, Messenger & Paymaster Robbery:

Deductibles:
Co-Ins:
Limit Insurance:

Broad Form Money & Securities (overnight coverage is linited to $250 subject to a ULC/CSA approved minimum Class 2 safe or better)

Deductibles:
Co-Ins:
Limit Insurance:

Safe Burglary (ULC / CSA Approved Minimum Class 2 Safe Or Better)

Deductibles:
Co-Ins:
Limit Insurance:

Libaillity:

Liabillity - Occurance Form - CGL

Deductibles:
Co-Ins:
Limit Insurance:

Tennant Legal Libillity:

Deductibles:
Co-Ins:
Limit Insurance:

Medical Payments: ($10,000 Per Person / $10,000 Per Occurance):

Deductibles:
Co-Ins:
Limit Insurance:

Personal Injury:

Deductibles:
Co-Ins:
Limit Insurance:

Advertising Injury:

Deductibles:
Co-Ins:
Limit Insurance:

Non-Owned Automobile - SPF #6:

Deductibles:
Co-Ins:
Limit Insurance:

S.E.F. #99 Excluding Long Term Leased Vehicles Endorsement:

Deductibles:
Co-Ins:
Limit Insurance:

Other Coverage Type:

Other Name:
Deductibles:
Co-Ins:
Limit Insurance:

Broker Declaration

Is This Account New To Your Office?

Yes

No

Is The Applicant Financially Sound?

Yes

No

Do You Reccomend This Applicant?

Yes

No

If No, How Long Have You Known The Applicant?

Have You Personally Seen This Property?

Other Comments:

Completion of this application does not bind the company to provide the insurance.

It is agreed, however, that this application shall form the basis of the contract, should the policy be issued by the Company. I declare that to the best of my knowledge and belief, all the foregoing statements are true and that these statements are the declarations upon which an insurance policy may be issued.

Consumer and previous insurer reports containing personal, credit, factual, or investigate information about the applicant may be sought in connection with this Application for insurance or any renewal, extension, or variation thereof. All provisions contained in the various forms issued under this contract shall be deemed to be contained in the present Application of insurance .

The policy may be deemed to be void and claims may be denied where:

An Applicant for a Contract:

a) Provides false or erroneous information to the prejudice of the insurer; Or

b) Knowingly mis-represents or fails to disclose in the Application any fact required to be stated therein; Or

The insured contravenes a term of the Contract or commits a fraud; or
The insured willfully makes a false statement in respect of a claim under the Contract

I CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND ACCURATE AND APPLY FOR A CONTRACT OF INSURANCE BASED UPON THE TRUTH OF THE STATEMENTS.

I AM IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE CONTRACT BETWEEN THE INVOLVED PARTIES.

Signature Of Applicant: *

Clear

Date Signed: *

Name On Application: *

Position: *

Signature Of Broker:

Clear

Date Broker Signed:

Name Of Broker:

Roof:
Plumbing:
Electricity:
Heating:

Roof:
Plumbing:
Electricity:
Heating:

Mark Nantais is a lisenced insurance broker operating under Mitchell Sandham Insurance Inc. a division of Hub Intertnational