2. Date of Incorporation or Charter of Organization:
Under What Statute
Has the organization operated continuously from this date?
Yes No
3. Is the Organization exempt from Federal and Provincial Income taxes? . Yes No
Has the Organization filed a Federal Income Tax return for any of the last five years? . Yes No
If yes, have the returns been accepted as filed? Yes No
If no, furnish details:
4. Please provide the following information concerning the Organization
(a) Total number of directors
(b) Total number of officers
(c) Total number of professionals and their professions (e.g. social worker, occupational therapist, etc.).
(d) Total number of employees other than volunteers
(e) Total number of volunteers
5. Please list and describe the function of all of the committees responsible to the Board of Directors.
SECTION I - Directors and Officers Liability Insurance
Please only complete if you wish to renew or acquire this coverage.
A. DESCRIPTION OF OPERATIONS
1. Please provide a complete description of the Organization's operations.
2. (a) Total Budget for next 12 months (if necessary, please do your best to estimate based on your Organizations Total Budget for the current fiscal year):
(b) Please identify the source of funds and percent of revenue attributable to each:
3. Are there any loans outstanding or anticipated to any person(s) applying for insurance
in their capacity as either a director, trustee, officer, volunteer, employee or
committee member of the Organization or Organization(s) controlled by them? Yes No
If yes, provide details.
4. Has the Organization, at any time over the past five years, been in breach of any of its debts, covenants, or loan agreements?
Yes No
If yes, provide full details.
5. Does the Organization publish any magazines, periodicals or newsletters? Yes No
(If Yes, attach a copy of each.)
6. Does the Organization evaluate or set standards for the qualifications and performance of
employees and/or volunteers representing your organization? Yes No
If yes, please elaborate.
7. Does the Organization carry out any disciplinary action, review activities or
issue licences and/or permits? Yes No
If yes, describe:
8. Does the Organization have any activities outside Canada? Yes No
If yes, describe:
9. Are employees given warnings prior to termination? Yes No
If yes, are they verbal or written?
10. Are the Directors involved with the majority of terminations? Yes No
B. PAST ACTIVITIES
1. Has any Insured proposed for coverage been involved in any of the following:
Any civil or criminal action or administrative proceeding? Yes No
If yes, describe:
Any representative actions, class actions or derivative suits? Yes No
If yes, describe:
Has the Organization received any inquiry, complaint, notice of hearing Yes No
from any provincial federal regulatory authority or legislative committee?
If yes, describe:
C. PRIOR INSURANCE
1. In the past five years, has any Insurer declined, cancelled or non-renewed any
application or policy for Directors and Officers liability or similar insurance? Yes No
If yes, describe:
2. In the past five years, has any Insured given notice of claim under the
provisions of any Directors and Officers liability or similar insurance? Yes No
If yes, describe:
3. In the past five years, has any Insured given notice under the provisions of
any Directors and Officers liability or similar insurance of specific facts or
circumstances which might give rise to a claim being made against any Insured? Yes No
If yes, describe:
D. LIMITS OF D&O INSURANCE REQUESTED Please select a limit of liability for your Directors & Officers Liability Insurance:
DIRECTORS & OFFICERS LIABILITY INSURANCE IS A CLAIMS MADE POLICY. IF A POLICY IS ISSUED, IT WILL COVER ONLY "CLAIMS" FIRST MADE AGAINST THE "INSURED PERSONS" AND REPORTED TO THE COMPANY DURING THE "POLICY PERIOD". "DEFENSE COSTS" ARE INCLUDED WITHIN THE LIMIT OF LIABILITY.
SECTION II - Property and General Liability Insurance Application
Please only complete if you wish to renew or acquire this coverage. Note well that you must obtain Directors & Officers Liability Insurance to be eligible for this coverage.
Please note that there will be an option to request coverage for additional locations that your Organization operates out of once this form is submitted.
Risk Address:
City:
Province:
Postal Code:
Years in Present Location?
Interest of applicant on property
If owner, please state building value: $
If owner, please list any Mortgagees or Loss Payees:
Are you the sole occupant?
Yes No
Total square footage of building?
How many square feet do you occupy?
If tenant, list the operations of the other tenants.
Building Detail
Building material:
Building Type:
If Other, please describe:
Year built:
If building is over 35 years old has it been fully gutted/renovated in the last 10 years? Yes No
If over 30, please select when the following services were last updated:
Wiring
Plumbing
Heating
Roof
Any other renovations completed and not noted above?
Sprinklered? Yes No
If Yes, state percent protected
Central Station Yes No
If Yes, state name of monitoring company
Fire/Alarm Protection
Please select a limit of liability for the following coverages:
Description
Standard Limits
Other Higher Amount
Contents of Every Description, Excluding EDP & Laptops:
Electronic Data Processing (EDP) Equipment (i.e. computer hardware and software):
Lap Top Computers
Please list the Make, Model, & Serial no. of all laptop computers to be insured:
Comprehensive General Liability Insurance
Is the space occupied by your Organization used or rented to third parties? Yes No
If yes, please describe the types of third party functions that occur (e.g. meetings, weddings, etc.)
If yes, are certificates of insurance obtained? Yes No
Please select a limit of liability for your Organizations Comprehensive General Liability coverage:
Does the Organization run any events that involve the serving of alcohol? Yes No
If yes, please describe:
SECTION III - ABUSE Liability Insurance Application
Please only complete if you wish to renew or acquire this coverage. Note well that you must obtain Directors & Officers Liability Insurance and Commercial General Liability Insurance to be eligible for this coverage.
In this questionnaire the term "abuse" means sexual, physical, emotional or psychological abuse, molestation or harassment, including corporal punishment.
1. Does the Organization abide by the abuse prevention and response protocols as endorsed by the Alzheimer Society of Canada?
Yes No
If you answered no, or if your Organizations abuse prevention and response protocols have changed since the most recent submission to LMS Prolink Ltd., please attach current abuse prevention and response protocols, at the end of this application.
2. What procedures do you follow to screen prospective employees or volunteers?
3. Have any allegations of abuse been made against you, your employees, volunteers or any other person associated with your organization in the last 10 years?
Yes No
If yes, describe full details (or attach all pertinent documentation of the incident(s) at the end of this application, if available).
WARRANTY STATEMENT
I have made reasonable inquiry of all persons proposed for coverage and I warrant that no person proposed for coverage is
aware of any facts or circumstances which (a) he/she has reason to suppose might afford valid grounds for any future
claim(s) that would fall within the scope of the proposed coverage or (b) indicate the probability of any future claim(s):
If there are no exceptions check "NO"
If there are exceptions check "YES"
Yes No
If yes, please describe:
False Information:
Any person who, knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
Defense Cost Provision:
Please note that the Defense Cost provision of this policy stipulates that the Limits of Liability may be completely exhausted by the cost of legal defense. Any deductible or retention may be similarly reduced or exhausted by legal defense costs.
Declarations And Signature:
The undersigned declares that to the best of his/her knowledge and belief the statements set forth herein are true. Although the signing of this application does not bind the undersigned on behalf of the Organization or its directors, officers or Insured Persons to effect insurance, the undersigned individually and on behalf of the Organization, its subsidiaries and their directors, officers or other Insured Persons agrees that this application and its attachments shall be the basis of the contract should a policy be issued and shall be attached to and form part of the policy. The Company is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary. The undersigned warrants that he/she is authorized and has the power to complete and execute this Application, including the Warranty Statement, on behalf of the Organization, its subsidiaries and their directors, officers or other Insured Persons.
If the information in this application materially changes prior to the Effective Date of this policy, the Organization will immediately notify the Company in writing and the Company may effect changes in the quotation.
SUBMITTED BY:
TITLE:
EMAIL:
DATED:
Additional Materials to be Submitted:
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Please attach to this application the following items of information:
Latest financial statements.
Schedule of Directors, Trustees and Officers
And, if there have been any changes to the following items since your last submission, please also attach:
A copy of the indemnification provisions of the Organization.
The by-laws, charter, articles or incorporation, trust indenture or other instrument from which the Organization derives its operating authority.
THIS APPLICATION FORM DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE APPLIED FOR HEREIN, THE INFORMATION PROVIDED ON THIS APPLICATION IS THE BASIS THE QUOTATION WILL BE CALCULATED ON.
An e-mail confirming the receipt of your submitted form will be sent to the above inputted e-mail address within 48 hours.
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