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Errors and Omissions / Commercial General Liability Application

Errors and Omissions and Commercial General Liability Insurance for the Members of the Canadian Association of Professional Speakers

Step 1 of 8

12%
  • THE APPLICANT

  • (c.) % Revenue Breakdown

    Totals from fields below must equal 100%.
  • Please enter a number less than or equal to 100.
    Please indicate a percentage from 0-100% for this field.
  • Please enter a number less than or equal to 100.
    Please indicate a percentage from 0-100% for this field.
  • Please enter a number less than or equal to 100.
    Please indicate a percentage from 0-100% for this field.
  • 9. Please provide a breakdown of your (the Applicant's) fees by category of services:

    Total from fields 9a and 9b must equal 100%.
  • Please enter a number less than or equal to 100.
    Please indicate a percentage from 0-100% for this field.
  • Please enter a number less than or equal to 100.
    Please indicate a percentage from 0-100% for this field.
  • If (b) was 0% - please enter "none" in this field.
  • INSURANCE COVERAGE

    If you are renewing your policy with ENCON, do not complete this section.
  • 11b.) If yes, please give the following details for the last three years:

  • LOSS EXPERIENCE

    If you are renewing a policy with ENCON, do not complete this section.
  • WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE INSURER, IT IS AGREED THAT IF THERE BE KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY CLAIM OR ACTION SUBSEQUENTLY EMANATING THEREFORM IS EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE.
  • LIMITS REQUESTED

    Please note that the proposed insurance will be effective at a date determined by the insurers.
  • APPLICANT'S CONSENT TO THE TRANSMISSION OF THE INFORMATION CONTAINED IN THE APPLICATION FORM:

    I hereby acknowledge that the information collected in the Application form is acquired by my insurance broker to be trasmitted to ENCON Group Inc. for the sole purpose of obtaining an insurance policy, and will be kept confidential.

    Moreover, I authorize ENCON Group Inc., its insurers or service providers to:

    • conduct verification, using outside sources, of the information contained in the Application form, in attached documentation and in subsequently provided documentation;
    • in the event of a claim, trasmit the submitted and verified information to loss adjusters, lawyers or other similar offices for the purposes of investigating, definding, negotiating or settling any claims, as required. For more information on ENCON's privacy policy, please contact privacy-officer@encon.ca.

  • DECLARATIONS AND SIGNATURE

    The undersigned Applicant for this insurance declares that, to the best of his/her knowledge and belief, the statemets set forth herein are true and correct and that reasonable efforts have been made to obtain sufficient information to facilitate the proper and accurate completion of this Application form. The undersigned further agrees that if any significant change int he condition of the Applicant is discovered between the date of this Application form and the effective date of the policy, which would render this Application form inaccurate or incomplete, notice of such change will be reported immediately in writing to the Insurance Manager. Although the signing of this Applicant form does not bind the Applicant to purchase the insurance, the undersigned Applicant agrees that this form and the information furnished pursuant hereto shall be the basis of the contract should a policy be issued and this form will become part of the policy.
  • Draw your signature into the box.
  • Commercial General Liability Insurance Application Information

  • 1. Insurance Coverage

  • 2. Location Details

  • If yes, when to:

  • 3. Physical Protection

  • Accepted file types: php, php3, php4, php5, phtml, exe, pl, cgi, html, htm, js.
  • Accepted file types: php, php3, php4, php5, phtml, exe, pl, cgi, html, htm, js.
  • COVERAGE OPTIONS

    Please choose one of the following coverage options:
  • I may have provided personal information in this document and by other means and I may in the future provide further personal information. Some of this personal information may inlcude, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and to my broker's or insurance company's policy regarding personal information, for the purposes of coummunication with me, assessing my application for insurance and underwriting my policies, renewals, changes of coverage, evaluating claims, detecting and preventing fraud, and analyzing business results.
  • This field is for validation purposes and should be left unchanged.
  • Program Offered Exclusively by

    All-Risks Insurance Brokers
  • All-Risks Insurance Brokers Ltd.

    1255 Ouellette Ave,
    Windsor, ON N8X 1J3

    Local: 519 253 6376
    Toll Free: +1 855 552 7467
    Fax: +1 855 552 7329

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