Contractors Insurance – HIFA Insurance Brokers

Business details:

Legal name

Operating name (if any)

Address

Street address

Unit#, etc.

City

Province

Postal code

Main phone

Main email

Website

Legal entity:

Sole proprietorship

Partnership

Incorporation

Other

Legal entity other:

Contact person details:

First name

Last name

Contact person's phone no

Contact person's email

Insurance details:

Current insurance company name (if applicable)

Current insurance policy number (if applicable)

Effective/renewal date

If renewal was not being offered, please explain.

Describe all claims, including any outstanding, and fees for the last five years including any accidents, facts, circumstances or allegations which may give rise to a claim:

What action has been taken to eliminate future accidents?

Has any similar insurance applied for or carried by the applicant been declined or cancelled by any insurer within the last three years?

Yes

If “Yes”, please provide full details.

Business risk assessment:

Business start date

No. of years of related prior experience

Please provide the following as accurate as possible: (Enter 0 for the past year if it is your first
year)

a) Past year

Payroll

Revenue

Work sublet

b) Next year estimate

Payroll

Revenue

Work sublet

Are company owners, executive officers or other office employees covered under worker’s compensation?

Yes

Please provide list of all operations performed and the breakdown for operation to the total revenue. (Use the + to add as many as needed)

Operation	%

Location of all of premises, operations, also indicate owner; lessee; tenant. (Use the + to add as many as needed)

Operation performed	Location address including postal code	O/L/T

Please list and describe all contracts over $100,000 in the past year. (Use the + to add as many as needed)

Details of all contracts over $100,000 in the past year.

Have you been involved in wrap-up policies in the past five years?

Yes

If “Yes”, please provide full details.

Business risk assessment continued:

If you checked any of the above operations, please provide full details of work undertaken.

What are the safety measures taken to protect the public on and off site?

Do you rent or lease mechanical equipment to or from others?

Yes, with operator

Yes, without operator

Are you bonded by a “contract surety” company?

Yes

How are waste materials disposed of? (Use the + to add as many as needed)

Waste material	Disposition details.....

Have you signed any contracts containing “hold harmless” clauses in favour of others?

Yes (You will be required to provide the copies of agreement)

Any additional relevant information you would like to share?

By submitting the above-mentioned information, the applicant declares that all statements made in the questionnaire and the information contained in documents submitted with it are true.

Submitting of this document does not bind the applicant to complete the insurance, but it is agreed that the questionnaire shall be the basis of the contract, should a policy be issued.

Business details:

Contact person details:

Insurance details:

Business risk assessment:

Business risk assessment continued:

Business risk assessment continued:

Finding exactly the right insurance coverage is not a daunting process at HIFA. We’ll make it straightforward and hassle-free so you’ll know exactly what you’re getting and can feel confident that you have the right coverage.