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| Is the Applicant a Financial Institution?: |
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| Is the Applicant involved in handling or training using firearms, explosives, dangerous chemicals or weapons?: |
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| Which of the following best describes the Applicant's legal status?: |
Private Company means a company that by its special Act, letters patent or supplementary letters patent:
- has restricted rights to transfer its shares
- that prohibits any invitation to the public to subscribe for its shares or securities. |
| Has the Applicant been in operation for at least 12 months?: |
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| Is the Applicant in arrears in its amounts payable on any federal or provincial government taxes?: |
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| Does the Applicant have any of the following in the USA: Premises/Operations? Subsidiaries? Employees?: |
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| Does the Applicant provide a pension plan to their employees?: |
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| Is the Applicant a Condominium Corporation or Strata Corporation?: |
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| Has there been a management buy-in (MBI) or buy-out (MBO) within the last two years?: |
*Answer Required for Private Companies Only |
| Has the Applicant incurred a pre-tax loss or negative net worth (share capital plus reserves) in any of its last two complete financial years or is a pre-tax loss or negative net worth anticipated in its current financial year?: |
*Answer Required for Private Companies Only |
| Is the Applicant and its subsidiaries insolvent or unable to meet their financial obligations as they fall due (including debt covenants or statutory obligations for taxes, pensions, benefits and wages)?: |
*Answer Required for Private Companies Only |
| Is the Applicant a Franchisor?: |
*Answer Required for Private Companies Only |
| Are at least 80% of the shares of the Applicant owned by their Directors, Officers or Employees or members of their families?: |
*Answer Required for Private Companies Only |
| A standard policy provides cover for employment claims brought against the individual directors and officers of the Applicant. Do you require a quotation to include cover for employment claims made against the entity itself?: |
*Answer Required for Private Companies Only |
| Has the Applicant had any claims which would fall within the proposed insurance coverage within the last 5 years?: |
*Answer Required for Private Companies Only |
| Has any director, manager, partner or trustee of the Applicant or any person insured or proposed for insurance (i) been convicted, or charged but not yet tried, of any criminal offence other than a motoring offence? or (ii) been declared bankrupt, gone into insolvent liquidation, or been the subject of receivership or an administration order?: |
*Answer Required for Private Companies Only |
| Is the Applicant aware of any fact or circumstance which could give rise to a claim against the Applicant or any of their present or former directors, managers, partner or trustees?: |
*Answer Required for Private Companies Only |
| To the knowledge of any director, manager, partner or trustee of the Applicant, has any company declined or terminated the insurance for the Applicant, any present director, manager, partner, trustee or for any predecessor in the business, past directors, managers, partners or trustees?: |
*Answer Required for Private Companies Only |
| By submitting this application you declare that the above statements and particulars are true and that you have not suppressed or misstated any material facts, and that you agree that this declaration shall be the basis of any binder or contract of insurance with the Insurer, and that the limits and deductibles as stated in the said binder or contract of insurance shall govern. It is understood and agreed that the completion of this application does not bind the Insurer to the issue of the insurance nor the Applicant to the purchase of the insurance. It is further understood and agreed that if, following submission of this application to the Insurer and prior to the date requested for coverage to be effective, the Applicant becomes aware of any information which has a bearing with regards to this application, the Insurer shall be immediately notified in writing of such information. Note: The policy does not cover any claim or circumstance stated above or any act, error, omission or circumstance which could give rise to a claim, of which the Applicant has knowledge prior to the inception of the policy.: |
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