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Commercial Insurance Online Application

PLEASE COMPLETE THIS FORM, THEN CLICK THE SUBMIT BUTTON AT THE BOTTOM. ANY FIELD IN RED IS A REQUIRED FIELD AND MUST BE COMPLETED.
BROKER
INSURED FIRST NAME  /  INITIAL LAST NAME
ADDRESS
CITY PROVINCE COUNTRY POSTAL CODE
PHONE # FAX # EMAIL
# EMPLOYEES FULL-TIME PART-TIME CNLA MEMBER PROP. EFF. DATE
CURRENT INSURANCE INFORMATION
TYPE INSURER PREMIUM
GENERAL INFORMATION
PERCENTAGE OF WORK CONTRACTED OUT?
DOES THE APPLICANT LEASE EQUIPMENT TO OTHERS...
      WITH OPERATORS?
      WITHOUT OPERATORS?
DOES OPERATION INVOLVE STORING, TREATING, DISCHARGING, APPLYING, DISPOSING OR TRANSPORTING OF HAZARDOUS MATERIALS? (E.G., CHEMICALS, WASTES, FUEL TANKS)
ARE ALL YOUR OPERATIONS FULLY LICENSED FOR PESTICIDES APPLICATIONS IN THE JURISDICTION OF OPERATION?
IF YOU CHECKED ANY OF THE ABOVE BOXES, PLEASE EXPLAIN WHY. PLEASE ALSO INCLUDE LICENSE CLASSES RELATING TO THE ABOVE QUESTION.
LIST TYPICAL CHEMICALS, HERBICIDES AND PESTICIDES USED IN OPERATIONS.

DESCRIPTION OF OPERATIONS (E.G., GARDEN CENTRE, GROWER, SNOWPLOUGHING, LAWN MAINTENANCE AND PESTICIDE/HERBICIDE APPLICATION). RECEIPTS
ADDITIONAL INSUREDS/LOSS PAYEES
NAME ADDRESS
CLAIMS HISTORY (3 YEARS) NO CLAIMS FILED  
LOSS DATE DESCRIPTION STATUS PAID
HAS ANY INSURER CANCELLED, DECLINED OR REFUSED TO RENEW ANY INSURANCE APPLIED FOR IN THE PAST 5 YEARS? IF SO, EXPLAIN BELOW.
PROPERTY
LOCATION 1:
ADDRESS
CITY PROVINCE COUNTRY POSTAL CODE
OPERATIONS
PROTECTION
HYDRANT <300m  FIRE HALL <10km  UNPROTECTED 
BURGLAR ALARMS
LOCAL  MONITORED  ULS 
FIRE ALARMS
LOCAL  MONITORED  ULS 
LOCATION 2:
ADDRESS
CITY PROVINCE COUNTRY POSTAL CODE
OPERATIONS
PROTECTION
HYDRANT <300m  FIRE HALL <10km  UNPROTECTED 
BURGLAR ALARMS
LOCAL  MONITORED  ULS 
FIRE ALARMS
LOCAL  MONITORED  ULS 
BUILDINGS - EXCLUDING GREENHOUSES
LOC # YEAR BUILT CONSTRUCTION HEATING TYPE VALUE CONTENTS LIMIT EXCLUDING GROWING STOCK
GREENHOUSE BUILDINGS
LOC # YEAR BUILT EXTERIOR COVERING CONSTRUCTION HEATING TYPE VALUE GROWING STOCK
EQUIPMENT BREAKDOWN
TYPE OF HEATING SYSTEM
STEAM OR HOT WATER BOILER
GAS FIRED UNIT HEATER
INFRARED HEATING
OTHER
SECONDARY HEATING SYSTEM:
# BACK-UP UNITS
TYPE OF BACK-UP
ADEQUATE TO MAINTAIN TEMP?
YES 
IF NO, PLEASE EXPLAIN WHY.
ALARM SYSTEM
ALARM MONITORS
YES 
GREENHOUSE TEMP
ELECTRIC POWER
HEATING EQUIPMENT
PROCESS EQUIP CONTROLLERS
SMOKE DETECTORS
ALARM INDICATORS LOCAL   OWNER'S RESIDENCE 
IF NEITHER OF ABOVE, DESCRIBE.
BACK-UP POWER
YES 
STANDBY ELECTRIC POWER GENERATOR
LOCKED IN STANDBY POSITION
ADEQUATE TO MAINTAIN VENTILATION IN SUMMER?
YES 
IF NO, PLEASE EXPLAIN WHY.
REFRIGERATION SYSTEMS
ARE THERE REFRIGERATION SYSTEMS?
YES 
# COOLERS/FREEZERS
BACK-UPS ON PREMISES?
YES 
IF YES, PLEASE DESCRIBE.
ALTERNATE STORAGE FACILITIES?
YES 
IF YES, PLEASE DESCRIBE.
TEMPERATURE ALARMS?
YES 
IF YES, DO THEY INITIATE
LOCAL ALARMS
OWNER'S RESIDENCE
OTHER
$ VALUE OF CROP IN STORAGE AT COST
MARKET VALUE OF CROP IN STORAGE
CROP SPOILAGE TEMP (F)
LOW
HIGH
UTILITY POWER INTERRUPTION
FREQUENT POWER INTERRUPTIONS (>1/MONTH)
YES 
IF YES, PLEASE EXPLAIN.
LONGEST INTERRUPTION IN LAST 3 YEARS
CONTRACTORS EQUIPMENT SCHEDULE (REPLACEMENT VALUE ON ITEMS 3 YEARS OF AGE OR NEWER)
# YEAR MAKE MODEL DESCRIPTION SERIAL # AMT OF INSURANCE
TOOL FLOATER (MAXIMUM $1,000 ANY ONE ITEM, PAIR OR SET)
ACTUAL CASH VALUE
LIMIT RATE CASH VALUE


 

 
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