B Smart - Commercial General Liability Application Form

B Smart - Commercial General Liability Application Form
Important Notice
This is a proposal for a contract of insurance, in which Applicant or you/your means the individual, company, partnership, limited liability partnership, organization or association proposing coverage. This proposal must be completed, signed and dated. All questions must be answered to enable a quotation to be given. Completion does not bind you or Underwriters to enter into any contract of insurance. If space is insufficient to answer any questions fully, please attach a signed continuation sheet. You should retain a copy of the completed proposal and any supporting information for future reference. All facts material to the proposed insurance must be disclosed, fully and truthfully to the best of your knowledge and belief. Failure to do so may make the contract of insurance voidable or severely prejudice your rights in the event of a claim. A material fact is one likely to influence Underwriters' assessment or acceptance of the proposal. If you are uncertain what may be a material fact, you should consult your broker. You are recommended to request a specimen copy of the proposed policy wording from your insurance broker and to consider carefully the terms, conditions, limitations and exclusions applicable to the coverage.
Broker Information
Broker Name

First NameLast Name
Broker Email Address
example@example.com
Broker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Brokerage
Applicant Information
Name of Applicant / Insured, as it should appear on the policy:
Applicant / Insured Contact First & Last Name

First NameLast Name
Contact Email Address
example@example.com
Contact Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Include the name of all subsidiaries or affiliated entities to be insured, or attach a separate sheet if necessary.
Attach additional subsidiaries or affiliated entities to be insured

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Postal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location Address, if different than postal address above:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website Address:

Premises Information
Premises Details - Please add each premises. Use the "Add Premises" button for each premises location. Alternatively, attach separate Statement of Values if necessary.
Attach Statement of Values if necessary

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Please specify which of your locations are leased/rented out, and detail the tenant arrangements.
Provide details of the extent and nature of third-party visitors to your premises:
Describe adjacent exposures, if any:

Revenue & Coverage Requirements

Detail the amount of annual revenue:

Rows	Currency	2024	2025	2026	2027
Canada
USA
Other

Date of your fiscal year end:

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Limit of liability required, please specify currency:
Do you require General Liability?
Do you require Products Liability?
Coverage start date:

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate

Insurance History
Have you previously been insured or are you currently insured?
a) Name of Insurer
b) Limit of Liability
c) Premium
d) Deductible
e) Date of Expiry

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
During the past 5 years, has any company ever cancelled, declined or refused to issue similar insurance to the Applicant?
If Yes, provide full details:
Have you or any of your directors or partners ever been charged with a criminal offence other than a motor vehicle offence?
If Yes, provide full details:

Claims History
Please provide loss experience for the last five years, including total costs from the ground up for each claim, whether insured or not, including defence costs and expenses. Include loss experience of companies which have been taken over or merged with your company.

Claims History

Rows	Date of Occurrence	Describe Occurrence & Injury or Damage	Currency	Reserve Amount	Paid Amount	Expenses Amount	Deductible Amount	Status
1
2
3
4
5

Are you aware of any other incidents which may result in a claim against you?
If Yes, provide full details:

Loss Prevention
Do you have a Health and Safety Policy which is available to your employees and visitors?
If Yes, attach a copy:

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Do you have written procedure for the handling of complaints about your products or services and accidents or injuries involving your products or services?
If Yes, provide full details:
Do you provide first aid facilities?
If Yes, provide full details:
Do you employ a security officer and/or loss prevention engineer?
If Yes, provide full details:

Required Attachments
Please check to ensure that all questions have been answered and that you have attached the following:
- A copy of your standard form of contract, agreement or letter of appointment, if utilized
- A copy of any brochure or sales literature available in relation to your activities
- Health and Safety policy
- Product brochures, catalogues, instruction manuals and product safety literature, if Products Liability coverage is required
- Any continuation sheets required to fully answer the application questions
File Upload

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Declaration
I hereby declare that I am authorized to complete this proposal on behalf of the Applicant and that the statements and particulars in this proposal are true and complete and no material facts have been mis-stated or suppressed.
I undertake to inform Underwriters of any material alteration or addition to these statements or particulars which occurs before any contract of insurance based on this proposal is effected, and acknowledge that this proposal, together with any other information supplied to Underwriters, shall be the basis of such contract.
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.
Signature of Applicant (authorized representative)
The signatory should be a director or senior officer of, or partner in, the Applicant
Confirm Form is Complete
BOS JotForm Submission Key
BOS JotForm Redirection
Should be Empty:

B Smart - Commercial General Liability Application Form

Important Notice

Broker Information

Applicant Information

Premises Information

Business Information

Revenue & Coverage Requirements

Subcontractors

Work Away From Premises

Products Liability Coverage Information

Quality Control & Record Keeping

Contractual Liability

Insurance History

Claims History

Loss Prevention

Required Attachments

Declaration

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