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

THE APPLICANT
1a.) Name of Applicant*
First Last
1b.) Business Operating Name
2. Are you a CAPS member in good standing?*
- Yes
- No
3. Your Web Site Address (if applicable)
4. Email Address*
5. Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
6. Phone*
7. Fax
8. Total Revenue*
(a.) Do you (the Applicant) provide services or perform activities outside Canada or for clients who are outside Canada?*
- Yes
- No
(b.) If yes, please provide the gross annual fees or income from the past year and anticipated for the next year.
(c.) % Revenue Breakdown
Totals from fields below must equal 100%.
Canada*
Please enter a number less than or equal to 100.
Please indicate a percentage from 0-100% for this field.
US*
Please enter a number less than or equal to 100.
Please indicate a percentage from 0-100% for this field.
Other*
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%.
(a) Public Speaking including related keynote speaking, training, facilitating and coaching in connection with public speaking:*
Please enter a number less than or equal to 100.
Please indicate a percentage from 0-100% for this field.
(b) All other services*
Please enter a number less than or equal to 100.
Please indicate a percentage from 0-100% for this field.
Describe all other services from (b) in detail*
If (b) was 0% - please enter "none" in this field.
10. Have you (the Applicant) ever been investigated by or suspended from practice by any governing body of your profession?
- Yes
- No
If yes, please provide details:

INSURANCE COVERAGE
If you are renewing your policy with ENCON, do not complete this section.
11a.) Have you (the Applicant) ever previously purchased professional liability or errors and omissions insurance?
- Yes
- No
11b.) If yes, please give the following details for the last three years:
Insurer #1
Period
Limit
Expiring Premium
Deductible
Insurer #2
Period
Limit
Expiring Premium
Deductible
Insurer #3
Period
Limit
Expiring Premium
Deductible
11c.) With respect to the information provided above, please indicate if such coverage was offered on an occurence basis or claims-made basis:
11d.) If claims-made, what was the retroactive date of the policy
12a.) Has insurance coverage ever been declined or cancelled or the renewal thereof been refused?
- Yes
- No
12b.) If yes, please describe reasons for insurance not being covered.

LOSS EXPERIENCE
If you are renewing a policy with ENCON, do not complete this section.
13a.) In the past, has the Applicant or any of his/her employees ever been the recipient of any allegations of professional negligence in writing or verbal?
- Yes
- No
13b.) Is the Applicant or any of his/her employees aware of any facts, circumstances or situations which may reasonably give rise to a claim, other than as advised above?
- Yes
- No
13c.) If yes, please describe below:
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
14. Public Speaking (choose one of the following):
- Limits: $1,000,000/$1,000,000 | Deductible: $1,000 | Premium: $250
- Limits: $2,000,000/$2,000,000 | Deductible: $1,000 | Premium: $325
- Limits: $3,000,000/$3,000,000 | Deductible: $1,000 | Premium: $475
- Limits: $4,000,000/$4,000,000 | Deductible: $1,000 | Premium: $625
- Limits: $5,000,000/$5,000,000 | Deductible: $1,000 | Premium: $750
Please note that the proposed insurance will be effective at a date determined by the insurers.
15.) All other modalities to be referred for rating.

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.
APPLICANT'S CONSENT*
- I agree to the information above.

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.
Name of Applicant*
First Last
Signature of Applicant*
Draw your signature into the box.
Date*

Each application will be subject to a $25 application processing fee.*
- I accept the $25 processing fee.
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.
Please draw your signature in the box below:*
Date*
Comments
This field is for validation purposes and should be left unchanged.

Errors and Omissions / Commercial General Liability Application

Step 1 of 8

THE APPLICANT

(c.) % Revenue Breakdown

9. Please provide a breakdown of your (the Applicant's) fees by category of services:

INSURANCE COVERAGE

11b.) If yes, please give the following details for the last three years:

LOSS EXPERIENCE

LIMITS REQUESTED

APPLICANT'S CONSENT TO THE TRANSMISSION OF THE INFORMATION CONTAINED IN THE APPLICATION FORM:

DECLARATIONS AND SIGNATURE

Commercial General Liability Insurance Application Information

1. Insurance Coverage

2. Location Details

If yes, when to:

3. Physical Protection

COVERAGE OPTIONS

Program Offered Exclusively by

All-Risks Insurance Brokers Ltd.