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					               Chubb Insurance Company of Canada                                                 APPLICATION
                                                                                                 Installation/Builders Risk



                            By completing this APPLICATION you are applying for coverage with
                                  Chubb Insurance Company of Canada (the "Company")


1.   Name of Applicant:
2.   Address of Applicant:

     Phone:      (      )                                                      Fax:     (        )
     E-mail address and/or Web site address:
3.   Describe in detail type of work to be performed
     (including actual work performed by Applicant):
4.   Largest job performed in the last 3 years:
     a. Description:
     b. Located at:
     c.   Contract price:     $                                  Duration of job:
5.   Average work performed during the last 3 years:
     a. Total number of contracts completed:
     b. Duration of average contract:
     c.   Duration of longest contract:
     d. Average contract price:                              $
6.   Gross income from contracts for each of the last 3 years:                  Year:                   $
                                                                                Year:                   $
                                                                                Year:                   $
7.   Estimated gross income from Installation/Builders Risk during the next 12 months:                  $
8.   Labour charges average approximately                        %   of contract prices.
9.   Contracts presently underway:

                             Description and Location                                       Contract Price   Fire and EC Rate, if known

                                                                                        $
                                                                                        $
                                                                                        $
                                                                                        $
                                                                                        $
                                                                                        $
                                                                                        $
10. Limits Of Insurance desired:          a)   At job site:                     $
                                          b)   In transit:                      $




APPLICATION – Installation/Builders Risk                                                                                     Page 1 of 3
Form 04-03-06 (Rev. 3-80)
                                            c)   At temporary location:               $
                                            d)   Flood and earthquake:                $
11. Describe all losses, insured or uninsured, during the last 3 years involving property covered by this form of policy.
    Give date, place, cause and amount of each loss. Use separate sheet, if necessary.
    If NONE, state NONE.


12. List present carrier(s) for:      General Liability:
                                      Workers’ Compensation:
                                      Commercial Auto:
                                      Surety:
13. Nature of contemplated occupancy.
    CONSTRUCTION – Give full details:
     Area:    Length:                             Width:                             Height:                          No. of stories
     Foundation material:            Concrete block          Concrete           Reinforced Concrete              Other:
     Foundation on:                  Natural ground          Pilings         Fill         Other:
     Walls construction:             Brick        Hollow tile       Concrete block             Metal       Other:
     Ceilings construction:          Tile        Plaster        Metal        Other:
     Floor construction:             Mill        Ordinary joist         Reinforced Concrete             Other:
     Roof construction:              Mill        Ordinary joist         Reinforced Concrete             Other:
     Roof exterior:                  Shingled            Compo.         Metal         Other:
     Will there be any high towers, steeples, or smoke stacks?                                                                           Yes     No
     If yes, please describe:
     PROTECTION:                Public Fire Dept. Class:                                                                  Unprotected

                                Watchman service – Describe:
     Will non-union labour be used?                Yes      No                      Will local labour be used?              Yes     No
     CONTRACTOR:
     Reputation or credit rating:                                                                  Has he done this type of job?         Yes     No
     Does contract price include plumbing?                 Yes          No                Heating?          Yes       No
                                Air conditioning?          Yes          No                Electrical?       Yes       No
     Is coverage desired on temporary structures, scaffolding, supporting timbers for hoists and other rigging
     and similar devices?                                                                                                                Yes    No
     Is full value of these items included in contract price?                                                                            Yes    No
     If no, what is Full Value?       $
14. Additional information and comments, including subcontractors normally used by type:


15. Are sub-contractors to be covered by this insurance?                             Yes       No
16. If coverage is desired on tools and equipment used by this contractor, add Application Form 04-03-05.


NOTICE



APPLICATION – Installation/Builders Risk                                                                                                  Page 2 of 3
Form 04-03-06 (Rev. 3-80)
       The Applicant's submission of this Application does not obligate the Company to issue, or the Applicant to
       purchase, a policy. The Applicant will be advised if the Application for coverage is accepted.

MATERIAL CHANGE
       If there is any material change in the answers to the questions in this Application before the policy inception date,
       the Applicant must immediately notify the Company in writing, and any outstanding quotation may be modified or
       withdrawn.

FALSE INFORMATION
       Any person who, knowingly and with the intent to defraud any insurance company or other person, files an
       application for insurance containing any false information, or conceals, for the purpose of misleading, information
       concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

DECLARATION AND SIGNATURE
       I have read the above Application. I declare that to the best of my knowledge and belief the statements and
       information in this Application and any attachments thereto are true, accurate and complete. This information is
       given to the Company for the specific purpose of obtaining insurance coverage. It is agreed that if any information
       given in this Application or in any attachments thereto is materially false, inaccurate or incomplete, the Company
       may deny coverage or cancel the policy.




                                   Date                               Authorized Signature




                              Print Name                                                     Title



                 Submitted by:

                        Agency:

                         Phone:     (      )               Fax:   (       )

                         E-mail:


PLEASE NOTE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE
AUTHORIZED TO SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE NOT AUTHORIZED
TO BIND COVERAGE. NO COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE
APPLICATION AND BINDS THE COVERAGE.




APPLICATION – Installation/Builders Risk                                                                            Page 3 of 3
Form 04-03-06 (Rev. 3-80)

				
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