insurance application for the professional convention management associaiton (pcma) · 2020. 6....

PCMA Insurance Program Renewal Appl icat ion (04 18 16) Page 1 of 5

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:



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.



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



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



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:

insurance application for the professional convention management associaiton (pcma) · 2020. 6....

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