insurance application for the decorators & designers ...€¦ · insurance application for the...

DD A Insu rance P ro gra m N ew Bus iness Appl icat ion ( 04.0 3.1 7 ) of 7

PROLINK | 480 University Ave. Suite 800 Toronto ON. M5G 1V2 | TF: 800 663 6828 | F: 416 595 1649 | E: [email protected]

INSURANCE APPLICATION FOR THE DECORATORS & DESIGNERS

ASSOCIATION OF CANADA (DDA) New Business Application

SECTION 1: APPLICANT INFORMATION PLEASE READ CAREFULLY: THIS IS AN APPLICATION FORM FOR A CLAIMS MADE POLICY. All questions must be answered completely. If there is no answer,

write “none” or “n/a” in the space provided. Where space provided is insufficient to fully answer, please use separate page. 1. Name of Business: 2. Are you incorporated? YES NO 3. Are you a member in good standing of DDA? YES NO

4. DDA Membership Number: 5. Name of the Principal / Owner of the Business:

Phone #: Fax #: Email:

Mailing Address:

City: Province: Postal Code:

Website Address:

6. Do you rent, lease or own office space? YES NO

SECTION 2: UNDERWRITING DETAILS 7. Please complete the following table:

Please indicate the types of decorating services your firm provides to your clients and the estimated revenues from each service. Please indicate $0 if your firm does not provide the service listed and/or if a subcontracting firm is performing the service.

Service Provided Estimated Revenues for the Next 12 Months Residential Decorating Services: $

Commercial Decorating Services: $

Design Services $

Home Staging Services $

Electrical Services: $

Plumbing Services: $

General Contracting Services: $

Landscape Design Services: $

* Structural Design Services: $

Actual Construction, Installation, or Erection: $ ** Product Sales Manufactured by a Third Party:

(please list types of products and revenue breakdown below) $

________________________________________________________ $

________________________________________________________ $

Other: __________________________________________________ $ *NOTE: Please request the supplemental designer application from PROLINK if you provide structural design services.

**NOTE: If you are purchasing CGL coverage and your product sales make up more than 50% of your total revenues then you MUST purchase products liability coverage under Option D on page 3 of this application.



8. Do you provide Home Stating Services? YES NO

If yes, a. Do you use professional movers? YES NO b. Do you use storage facilities? YES NO

9. Please complete the following table: Do you currently carry any Commercial General Liability or Professional Liability insurance? If “YES” please provide the following details below:

Current Insurer:

Policy #:

Premium:

E&O Limits of Insurance: Expiry Date:

CGL Limits of Insurance: Expiry Date:

Office Contents Limits of Insurance: Expiry Date:

10. Have you ever been the recipient of any allegations of professional YES NO

negligence either in writing or verbally?

11. Are you aware of any facts, circumstances or situations, which YES NO may reasonably give rise to claim, other than advised above?

12. Have you reported any Commercial General Liability or

Office Property claims in the past 5 years? YES NO If “YES” please give details:

13. Has any insurer ever declined, cancelled or imposed special conditions for any coverage for you or your entity in the past? YES NO If “YES” please give details:



PLEASE NOTE: The minimum retained premium noted in the charts below indicate the amount retained by the insurer when it is GREATER than the earned premium for your time insured with Berkley Insurance Company (in the event the policy is cancelled mid-term).

1. The prorated premium for a short-term policy (the master policy expires June 1, 2018). 2. The earned premium for your time insured with Berkley Insurance Company in the event the policy is cancelled mid-term.

SECTION 3: COVERAGE FOR E&O LIABILITY AND COMMERCIAL GENERAL LIABILITY INSURANCE

OPTION A – E&O LIABILITY ONLY PLEASE NOTE: Option A is for E&O Liability ONLY.

Please select the appropriate premium:

Option A – E&O Protection for services provided by up to TWO accredited Interior Decorators or Designers as recognized by DDA.

Annual Premium

Minimum Retained Premium

Limit:

Base Premium

$500,000 limit per claim and $500,000 annual aggregate limit ($0 deductible): $408.00 $100.00

$500,000 limit per claim and $1,000,000 annual aggregate limit ($0 deductible): $485.00 $150.00

$1,000,000 limit per claim and $1,000,000 annual aggregate limit ($0 deductible): $552.00 $175.00

$2,000,000 limit per claim and $ 2,000,000 annual aggregate limit ($0 deductible): $740.00 $200.00

OPTION B – ADDITIONAL PROFESSIONALS Please list all designated professionals working for your firm:

Name of Professional: Job Position:

The E&O policy premium in Option A will provide coverage for up to 2 professionals, INCLUDING YOURSELF.

For firms with 3 or MORE professionals, you MUST purchase additional coverage.

Please select the appropriate additional premium PER additional professional employed.

AII coverage opted for must share the same limit of liability as that chosen in Option A above.

Please select the appropriate premium:

Option B – Additional Professionals Annual Premium


Limit: Base Premium Per Professional

$500,000 limit per claim and $500,000 annual aggregate limit ($0 deductible): $78.00 $25.00

$500,000 limit per claim and $1,000,000 annual aggregate limit ($0 deductible): $88.00 $35.00

$1,000,000 limit per claim and $1,000,000 annual aggregate limit ($0 deductible): $97.00 $45.00

$2,000,000 limit per claim and $ 2,000,000 annual aggregate limit ($0 deductible): $134.00 $60.00



OPTION C – ADDITION OF COMMERCIAL GENERAL LIABILITY (CGL)

Commercial General Liability (CGL) can protect you against claims brought against you for bodily injury or property damage sustained by a third party (i.e., your customers).

Please select the appropriate premium required:

Option C – CGL Annual Premium


Limit: Base Premium

$1,000,000 limit per occurrence and $1,000,000 annual aggregate limit: ($1,000 deductible) $255.00 $75.00

$2,000,000 limit per occurrence and $ 2,000,000 annual aggregate limit: ($1,000 deductible) $332.00 $100.00



OPTION D – PRODUCT SALES LIABILITY COVERAGE

If you are purchasing CGL coverage and your product sales make up more than 50% of your total revenues then you MUST purchase products liability coverage. Please note if you elect this coverage the limit selected MUST match that of the CGL limit selected above. This coverage can only be purchased with the CGL policy.

Please select the appropriate premium required:

Option D – Product Sales Liability Coverage Annual Premium


Limit: Base Premium







SECTION 4: PROPERTY AND CRIME INSURANCE

OPTION E - OFFICE PACKAGE - PROPERTY AND CRIME INSURANCE

Please note you MUST have CGL insurance in place in order to be eligible for this coverage.

Option E - Office Package Annual Premium


$30,000 Business Contents (including Exterior Signs and Electronic Data Processing Equipment and Media) * excludes laptops $410 $50

*Higher limits available for additional premium I would like a quote for higher limits

PLEASE NOTE: If this is your first time purchasing this coverage, a supplemental application will need to be completed. Please contact [email protected] to obtain a copy of this document.

If you are renewing your office package, please answer the questions below:

1. Have there been any changes to your location? YES NO

2. Have there been any changes to your operations? YES NO

3. Do you require any changes to the current limits of insurance you carry? YES NO

If you have answered “YES” to any of the above questions, OR if you require a quote for higher limits than listed in the above chart, a supplemental application will need to be completed. Please contact [email protected] to obtain a copy of this

document.



SECTION 5: PREMIUM SUMMARY

SECTION 3 - COVERAGE FOR L IABILITY INSURANCE

Option A – Errors & Omissions Insurance: $

+

Option B – Additional Professionals (if selected): $

+

Option C – CGL Coverage (if selected): $

+

Option D – Product Sales Liability (if selected): $

SECTION 3 SUBTOTAL: $

SECTION 4 – PROPERTY INSURANCE

Option E – Office Package(if selected): $

SECTION 4 SUBTOTAL: $

PROGRAM ADMINISTRATION FEE: $20

SECTION 3 + SECTION 4 SUBTOTAL+ FEE:

PST (8% for Ontario Residents) or RST (8% for Manitoba Residents) or

HST (15% for Newfoundland Residents) or PST(6% for Saskatchewan Residents) or

QST (9% for Quebec Residents):

GRAND TOTAL (SECTION 3 & 4 TOTAL + PROGRAM ADMIN. FEE + TAXES ): $

ADDITIONAL FEES: Please note a $35 fee will be assessed for any transaction declined due to non-sufficient funds.



IMPORTANT NOTICE TO APPLICANT:

This is an application for insurance and the insurer is not obligated to accept the applicant for coverage. If a policy is issued, one signed copy of the application will be attached to the policy or certificate. Signature on the application form and submission of a premium payment does not bind the insurer to complete an insurance transaction with the applicant. This policy provides Errors and Omissions insurance that applies on a claims-made basis. The following provides a general description of this coverage and is subject to the terms and provisions of the actual policy.

A. The policy will not cover any losses from incidents which take place before the Retroactive Date, if any, or after the expiration of the policy period (subject to the Extended Reporting Period provision).

B. The policy will provide coverage for losses from incidents which take place on or after the Retroactive Date, if any, but before the beginning of the policy period only if the insured did not know of the incident before the beginning of the policy period.

C. The policy will not cover any loss for which a claim is first made after:

1. The expiration of the policy period or its earlier termination date, if any; or

2. The Extended Reporting Period if any and then only in accordance with the terms described in the policy.

D. The policy will only cover claims which are first made:

1. During the policy period; or

2. During an Extended Reporting Period if any and then only in accordance with the terms and conditions described in the Extended Reporting Period Section of the policy.

E. Please request a copy of the Policy and review the terms and conditions to obtain more information.

F. The limits for Defence Costs are over and above the liability and will not reduce the limit of liability.

Disclosure and Consent:

As part of my application for insurance I consent to the collection and use of personal information required for the purposes of considering my application for insurance by the insurer and the authorized insurance broker for Ontario Applicants, LMS PROLINK Ltd., and/or the authorized insurance broker for applicants outside of Ontario, The PROLINK Insurance Group Inc. The insurer and the broker are authorized to collect, use, and disclose personal information and provide such personal information to third parties, as required for the purpose of underwriting this application for insurance, as permitted by the relevant provincial and federal privacy laws or other applicable laws, and as required by the applicant’s association and/or governing body. I understand that at any time I may ask to review the personal information pertaining to my application for insurance and the insurer and broker will be obligated to provide me with any information I am entitled to receive under the relevant provincial and federal privacy laws or other applicable laws. I have reviewed the information in this Application, gathered information from all partners/directors/ officers/ employees/agents under this entity whether present or prior regarding their knowledge or awareness of any claims or situations which may give rise to any claims The Claim Information Forms, if any, that are attached to this Application include the details of:

A. All facts, situations, and incidents which have occurred in the past and which may reasonably be expected to result in a claim, suit or arbitration against us (the Applicant);

B. All facts, situations, and incidents which have occurred in the past and which may reasonably be expected to result in a claim, suit or arbitration against us (the applicant) in the future. All such claims, suits and incidents have been reported to our (Applicants) current or prior insurer(s). It is understood and agreed that all such claims, suits, arbitrations, fact situations and incidents will be excluded from coverage under any policy issued by the insurer.

It is understood and agreed that failure to provide true and complete response to any of the questions, statements or request for information in this Application or to provide any other information material to this Application may, at the sole option of the insurer, result in the voiding of the insurance policy issued in reliance on this Application and /or denial of coverage for specific claims asserted against us (the Applicant) or any other insured under the policy. The undersigned on behalf of the Applicant and all other insureds under this policy issued by the insurer, hereby waives any defense to an action by the insurer for voiding or revoking of the policy based upon misrepresentation of fact or failure to disclose material information in connection with this Application. The Applicant agrees to hold the insurer harmless from all loss as a result of any such misrepresentation or failure to disclose, including, without limitation, all costs and attorney fees incurred by the insurer in connection with said action for voiding or revoking the policy. I HEREBY DECLARE that the above statements and particulars are true to the best of my knowledge, that I have not suppressed or misstated any facts and I agree that this application shall form part of the insurance policy. I also acknowledge that I am obligated to report any changes that could affect the disclosures in this application that occur after the date of signature, but prior to the effective date of coverage.

Applicant’s Signature:______________________ Name (please print): ______________________ Date: _______________

PLEASE COMPLETE AND RETURN THE APPLICATION THROUGH ONE OF THE FOLLOWING METHODS:

V ia EM AIL p le as e s en d to : DD A @P ROLI NK. i ns ure

V ia F AX p l ea se s e nd to : 416 595 16 49 att n. D DA PR OGR AM MA N AGE R

V ia M AIL p le as e se n d to : PROLINK | 480 University Ave. Suite 800 Toronto ON. M5G 1V2

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