• Assailant Smart

    Active Assailant Insurance Application Form

  • Broker Information

  • Format: (000) 000-0000.

  • Company Information

  • Format: (000) 000-0000.

  • Coverage Exposure and Values

  • Do you hold off-site activities that require coverage?
  • Do you have motor vehicle exposure?
  • Do you have onsite security?
  • Do you engage private security?
  • Do you occupy the entire building?
  • Do you have emergency evacuation procedures?
  • Do you have active assailant training and response procedures?
  • Do you obtain an independent review of the above procedures?
  • Do you conduct employee screening?

  • Coverage Options and Prior Loss History

  • In the last five years has there been any form of threat(s) or losses made in respect of this coverage?
  • Has the applicant ever been declined insurance, or has any insurer ever cancelled or declined to renew your policy?

  • Applicant Declaration

  • THE UNDERSIGNED HEREBY ACKNOWLEDGES THE TRUTH OF THE STATEMENTS CONTAINED HEREIN.

    I AUTHORIZE YOU TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION AS PERMITTED BY LAW, IN CONNECTION WITH YOUR COMMERCIAL INSURANCE POLICY OR A RENEWAL, EXTENSION OR VARIATION THEREOF, FOR THE PURPOSES NECESSARY TO ASSESS THE RISK, INVESTIGATE AND SETTLE CLAIMS, AND DETECT AND PREVENT FRAUD, SUCH AS CREDIT INFORMATION, AND CLAIMS HISTORY.

    For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Lloyd’s Underwriters’ insurance business in Canada.

    Signing this form does not conclude a contract of insurance or oblige insurers to issue a policy. I declare that to the best of my knowledge and belief the information given is accurate and constitutes a fair presentation of the risk and that no material information has been withheld. I agree that if the information given was provided to you by any person other than myself, that person shall be deemed to have been my agent for the purpose of providing that information

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