Do any operations take place outside of Canada?
Yes No If yes, how often:
Is equipment ever rented or leased to others without an operator?
Yes No
Are subcontractors required to carry liability insurance?
Yes No
If yes, what limit of liability insurance is required?
Are certificates of liability insurance always obtained from subcontractors before they are allowed to commence work? Yes No
Are formal contractual agreements entered into with subcontractors?
Yes No
Is any work carried out at any oil or natural gas production exploration or processing facility?
Yes No
Check if completed or planned projects include any of the following:
Blasting
Logging or Lumbering
Shoring or Underpinning
Bridges
iiiiiiiiMining
Structural Steel
Caissons
Oil Field Work
iiiiiiiiTunneling
Dams
Pile Driving
Use of Explosives
iiiiiiiiExcavating
Raising or Moving Buildings
Welding
Land Clearing
iiiiiiiiRigging
Wrecking
Gas Work
Open Flame Work
OPTIONAL COVERAGE
Extended business income:
Yes No Amount of Business Income Insurance
(Please Attach Completed Business Income Worksheet)
Amount of Gross Receipts $
Indemnity Period
12 Months
18 Months
24 Months
36 Months
Additional Increase in Cost of Operations
Automatic $25,000
Total Required
Fines or Damages
Automatic $25,000
Total Required
Ordinary Payroll: Limit $
30 Days 60 Days 90 Days 120 Days 180 Days Full Payroll
ADDITIONAL OPTIONAL COVERAGE
Flood
Yes No
Earthquake
Yes No
Sewer Back-up
Yes No
Nature of Ground
Flat
Hillside
Hilly
Swampy
Other
Soil
Filled Ground
Rock
Sand
Shale
Other
Equipment Breakdown on Self Propelled Units and Portable Equipment
Yes No
Fine Arts*:
Miscellaneous Property Broad Form*: Deductible
$1,000
$2,500
$5,000
Scheduled Builders risk:
Yes No If yes, please complete “Builders Risk Details” form on each project as required.
Umbrella:
Yes No If yes, please complete se