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PCMA Insurance Program Renewal Appl icat ion (04 18 16) Page 1
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LMS PROLINK Ltd. | 480 University Ave. Suite 800 Toronto ON. M5G
1V2 | TF: 800 663 6828 | F: 416 595 1649 | E: [email protected]
INSURANCE APPLICATION FOR THE PROFESSIONAL CONVENTION MANAGEMENT
ASSOCIAITON (PCMA)
Renewal Application
SECTION 1: APPLICANT INFORMATION
1. Name of Applicant:
2. PCMA Membership Number:
3. Form of Business: Individual Incorporated Organization
Partnership or Joint Venture Sole Proprietorship
4. Please provide the following details:
Mailing Address: City: Province: Postal Code: Phone: Fax: Email:
Website:
5. If you have other subsidiaries or holding companies list
these entities and describe operations of each:
6. A. Please indicate the types of clients served.
Government departments (federal, provincial or municipal): YES
NO
Private and public companies: YES NO
Non-profit organizations: YES NO
Private individuals or families: YES NO
Other types of clients (if applicable):
B. If you plan or manage events for non-profit organizations or
private individuals/families YES NO
do you receive confirmation that they maintain a minimum of
$1,000,000 of Commercial
General Liability insurance to cover the event?
If “NO”, please explain why:
7. Do you plan or manage consumer focused events (e.g., auto or
travel shows) where the YES NO
public pays a fee to attend?
If “YES”, please list these events:
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PCMA Insurance Program Renewal Appl icat ion (04 18 16) Page 2
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LMS PROLINK Ltd. | 480 University Ave. Suite 800 Toronto ON. M5G
1V2 | TF: 800 663 6828 | F: 416 595 1649 | E: [email protected]
8. Please provide number of employees:
9. Please provide total payroll for the last 12 months: $
10. Please provide gross fees and revenues from
operations/services provided:
A. Total Annual Gross Revenues: Last fiscal year-end: $
Current fiscal year (projected): $ Revenue derived from: Canada:
________ % United States: ________ % International: ________ %
NOTE: If coverage is granted, the Applicant must report any US
or Foreign Sales not indicated above, which may arise after this
application is completed.
B. Please indicate the percentage of services you physically
perform outside of Canada? _____% C. Please describe in detail your
U.S. operations? D. Do you maintain a physical office in the US or
outside of North America? YES NO
11. Describe the typical services provided by your
subcontractors (caterers, décor, etc.):
12. Do you receive confirmation from the following event/meeting
suppliers/subcontractors that they maintain a minimum of $1,000,000
Commercial General Liability insurance?
Caterers YES NO Bus Transport Companies YES NO
AV, Lighting YES NO Stage, Seating or Set Installers YES NO
If “NO”, please explain why:
13. Do you provide any meeting or event services in addition to
planning, managing and YES NO arranging (i.e. party rentals,
decorating, accepting payment for travel bookings etc.)?
If “YES”, please describe:
14. A. In the past, has the Applicant or any of his/her
partners, officers, employees or subsidiaries YES NO ever been the
recipient of any allegations of professional negligence in writing
or verbally
which may reasonably give rise to a claim? If “YES”, please
attach details.
B. Is the Applicant or any of his/her employees aware of facts,
circumstances, or situations YES NO which may reasonably give rise
to a claim, other than advised above? If “YES”, please attach
details.
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PCMA Insurance Program Renewal Appl icat ion (04 18 16) Page 3
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LMS PROLINK Ltd. | 480 University Ave. Suite 800 Toronto ON. M5G
1V2 | TF: 800 663 6828 | F: 416 595 1649 | E: [email protected]
SECTION 2: OFFICE PROPERTY INSURANCE SECTION
Please review the property section of your Northbridge policy in
order to determine if your coverage requirements changed in the
past 12 months. Call 1 800 663 6828 or email [email protected] if you
have questions on your existing coverage.
If there are no changes, please proceed to SECTION 3 of this
application.
Please complete the appropriate sections if you answer “YES” to
the following:
Office Location changes: YES NO If “YES”, please indicate
changes under Part A.
Office Content changes: YES NO If “YES”, please indicate changes
under Part B.
PART A - OFF ICE LOCATION CHANG ES
Have you eliminated any office locations? If ‘YES’, please
provide the address(es). YES NO
Have you acquired a new office location? If ‘YES’, please
provide the new address(es). YES NO What is your interest in the
new property? Owner Occupant
Building Details – Please provide the following details for your
new office location: Year built: _________ If building is over 30
years, has it been fully gutted/renovated in the last 10 years? YES
NO If “YES”, provide dates of updates for the following: Plumbing
________ Wiring ________ Roofing ________ Furnace ________ Heating
________
If other updates or renovations have been done, please provide
full details on another sheet.
Is the building in a strip mall? YES NO Is this an enclosed
mall? YES NO
Is this a stand-alone building? YES NO Are you the sole
occupant? YES NO Square feet you occupy: __________ Number of
stories: __________ Number of units: __________ Is the building
sprinklered? YES NO Hydrant protected? YES NO
Does it have smoke detectors? YES NO If “YES” how many? _______
Heat detectors? YES NO If “YES” how many? _______ Distance to
hydrant? __________ Distance to nearest fire hall? __________ Do
you have an Approved ULC Central Station Burglar Alarm System? YES
NO If “YES”, please provide name of monitoring company Do you have
an Approved ULC Central Station Fire Alarm System? YES NO If “YES”,
please provide name of monitoring company Describe any physical
barriers to entry: (For example: doors, locks, bars, etc.) Building
Construction Details – Please check one of the following:
Fire Resistive Reinforced Concrete with Concrete Roof Non
Combustible Masonry Walls with Steel Deck Roof Masonry – Sold Brick
or Concrete Block – with Wood Joist Roof or Floor Wood Frame, Brick
Veneer, Aluminum Siding over Frame with Wood Joist Roof or
Floor
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PCMA Insurance Program Renewal Appl icat ion (04 18 16) Page 4
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LMS PROLINK Ltd. | 480 University Ave. Suite 800 Toronto ON. M5G
1V2 | TF: 800 663 6828 | F: 416 595 1649 | E: [email protected]
PART B - OFF ICE CONTENTS CHANG ES
Increase Decrease Office Contents1 limit by:
Increase Decrease EDP2 limit by:
Increase Decrease Leasehold Improvement limit by:
Increase Decrease Business Interruption limit by: 1 Office
Contents includes Furniture, Fixtures, Stock, Supplies, etc.
2 Electronic Data Processing Equipment includes Computer
Hardware/Software, Phone Systems, Photocopier/Fax, etc.
SECTION 3: REQUESTED LIABILITY INSURANCE
NOTE: Please call 1 800 663 6828 or email [email protected] if you
need to understand your current limits of coverage for Liability or
Office Contents insurance. Please select your limit:
PROFESSIONAL LIABILITY ERRORS & OMISSIONS
COMMERCIAL GENERAL LIABILITY
$500,000
$1,000,000 $1,000,000
$2,000,000 $2,000,000
$3,000,000 $3,000,000
$4,000,000 $4,000,000
$5,000,000 $5,000,000
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PCMA Insurance Program Renewal Appl icat ion (04 18 16) Page 5
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LMS PROLINK Ltd. | 480 University Ave. Suite 800 Toronto ON. M5G
1V2 | TF: 800 663 6828 | F: 416 595 1649 | E: [email protected]
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 EMAIL p lease send t o : [email protected]
V ia FAX p lease send to : 416 595 1649 attn. PCMA PROGRAM
MANAGER
V ia MAIL p lease send to : LMS PROLINK Ltd. 480 Univers ity
Ave. Suite 800 Toronto, ON. M5G 1V2
Name of Applicant: PCMA Membership Number: 1: Off2: Off3: Off4:
OffMailing Address: City: Province: Postal Code: Phone: Fax: Email:
Website: Subsidiaries: Subsidiaries 2: 5: Off6: Off7: Off8: Off9:
Off10: Off11: Off12: OffOther types of clients if applicable: 13:
Off14: OffIf NO please explain why: 15: Off16: OffIf YES please
list these events: undefined_4: undefined_5: undefined_6:
undefined_7: Canada: United States: International: Outside of
Canada: Please describe in detail your US operations: 17: Off18:
Off11 Describe the typical services provided by your subcontractors
caterers décor etc: 11 Describe the typical services provided by
your subcontractors caterers décor etc 2: 19: Off20: Off21: Off22:
Off23: Off24: Off25: Off26: OffIf NO please explain why_2: 27:
Off28: OffIf YES please describe: 29: Off30: Off34: Off35:
OffPlumbing: Wiring: Roofing: Furnace: Heating: 36: Off37: Off38:
Off39: Off40: Off41: Off42: Off43: OffSquare feet you occupy:
Number of stories: Number of units: 44: Off45: Off46: Off47: Off48:
Off49: OffHow Many 1: 50: Off51: OffHow Many 2: Distance to
hydrant: Distance to nearest fire hall: If YES please provide name
of monitoring company: 54: Off55: OffIf YES please provide name of
monitoring company_2: 56: Off57: Off58: Off59: Off31: Off32:
OffYear built: 52: Off53: OffDescribe any physical barriers to
entry For example doors locks bars etc: Name please print: Date:
1A: Off2A: Off3A: Off4A: Off5A: Off6A: OffEliminated: Eliminated 2:
7A: Off8A: Off9A: Off10A: Off60: Off61: Off62: Off63: Off64: Off65:
Off66: Off67: Off68: Off69: Off70: Off71: Off72: Off73: Off74:
Off75: Off76: Off77: Off78: OffChanges 1: Changes 2: Changes 3:
Changes 4: