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Non-Profit
Business Name
Business Address
City
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Postal Code
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Telephone
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Website
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General E-mail
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Company E-mail
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Contact Name
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Requested Effective Policy Date
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Requested Policy Expiry Date
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Name of Applicant as it is to appear on the policy
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Name of Company (If different)
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Mailing Address
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Jurisdiction of Incorporation
Canada
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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Has the business been operating for more than three years?
Yes
No
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Description of Operations
Condo Corporation
Charity
Religious Organization
Labour Union
Education Organization
Not-for-Profit Other
Political Organization
Self-Regulatory Organization
Regulatory/Disciplinary Bodies
Professional Associations
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Please provide the names of any additional entities you wish to include in the proposed coverage
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Does the company have the authority to discipline, take any disciplinary actions, or recommend any disciplinary action to its members?
Yes
No
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If yes, please explain
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Has the company ever had its tax exempt status challenged, revoked, or suspended by the CRA or any equivalent governing body?
Yes
No
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What are the total assets of the company? (Round to nearest 500,000)
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What percentage of the company's assets are in the US? (Round to nearest 5%)
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What were the consolidated gross sales/revenues for the company's most recent fiscal year? (Round to nearest 500,000)
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What were the consolidated US sales/revenues for the company's most recent fiscal year? (Round to nearest 500,000)
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Did the company have a going concern note in its most recent audited annual financial statements and/or is the company in breach of any debt/loan agreements or covenants, and/or is the company currently, or has it at any time during the past three years been financially insolvent, or within the last year has it contemplated seeking creditor protection, or does it contemplate seeking creditor protection within the next six months?
Yes
No
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Is Employment Practices Liability Coverage required for the company?
Yes
No
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If No, it is understood and agreed that coverage for wrongful employment practices will be limited to the insured persons only and not the insured company(ies)
If Yes, please complete the following questions. If not, please skip the rest of this page.
Number of Employees
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Full time Canadian Employees
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Full Time US Employees
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Full time employees from other countries
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If other was filled, pleased list countries the employees are from
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For employees with a salary over $100,000 are all terminations subject to prior review by, and support from, external legal counsel?
Yes
No
N/A
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In the event the company downsizes more than 25% of the company's workforce, is the downsizing subject to prior review by, and support from, external legal counsel?
Yes
No
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Is Fiduciary/Pension Trust Liability Coverage required for the company?
Yes
No
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If No, it is understood and agreed that coverage will be limited to fiduciary wrongdoing in connection with health and welfare benefit plans only. If Yes, please complete the following questions, if No, please skip the rest of the page.
Defined Contribution Pension Plan Total Assets
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Defined Benefit Pension Plan Total Assets
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Check here if neither apply
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For Any/All Defined Benefit Plans only
Based on historical cash flow from operations can the company make all special payment requirements where applicable?
Yes
No
N/A
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Have there been any amendments to any plans that have resulted in, or are expected to result in, a reduction of benefits?
Yes
No
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Has any insured individual (whether acting on behalf of any company, any other organization or personally), in the past 3 years been involved in:
Any litigation, civil or criminal action, class action, derivative action, investigation or proceeding with respect to, including but not limited to the following: anticompetitive/antitrust, fair trade, copyright or patent, shareholder/securities, pollution or occupational health & safety (excluding employment or pension, retirement or health & welfare benefit plans)?
Yes
No
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Any employment or labour related litigation or proceeding which resulted in settlements or findings of more than $25,000 cumulatively?
Yes
No
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Any litigation or proceeding involving any sponsored pension, retirement or health and welfare benefit plans?
Yes
No
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If yes to any of the above, please explain
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Other than any items already reported under the previous page of this application and with respect to any coverage on this page which is not currently in force:
Directors and Officers Liability
Yes
No
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If yes, Date
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If yes, limit
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Other than any items already reported under the previous 2 pages of this application and with respect to any coverage on the previous page which is not currently in force:
Are there any claims made or now pending against any individual or company proposed for coverage?
Yes
No
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Does any insured individual or company have any knowledge or information of any facts or circumstances which could reasonably be expected to give rise to a claim under the proposed policy, including but not limited to the types of matters as noted in the last 2 pages?
Yes
No
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If yes, please explain.
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Submit
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