APPLICATION FOR QUEBEC AUTOMOBILE INSURANCE POLICY – Q.P.F. No 4 (Garage Form)

INSURER: / BROKER: / No
ITEM 1 –
Applicant’s full name and business address / Location of other premises where business is conducted:
(1)
(2)
(3)
ITEM 2 –
Contract period
/ From / Day / Month / Year* / To / Day / Month / Year* / *exclusively.
*12:01 a.m. standard time at the Applicant’s address stated herein as to each of said dates.
ITEM 3 – The automobiles in respect of which insurance is to be provided are those used in connection with the Applicant’s business described below and conducted at the locations specified in Item 1:
EMERGENCY SERVICE AND TOWING OF VEHICLES.
State name of creditor to whom loss, if any, under section B of the Insuring Agreements is payable to the extent of the creditor’s interest:
ITEM 4 – Insurance is hereby provided against one or more of the perils mentioned in this item, but only under the section(s) or subsection(s) for which a premium is specified and upon the terms and conditions of this contract and subject to the following amounts and deductibles.
INSURING AGREEMENTS / PERILS / AMOUNTS / DEDUCTIBLES / PREMIUM
Section A
Civil Liability / Bodily injury to or death of others or damage to their property / $
(Exclusive of interest, expenses and costs) for loss or damage resulting from bodily injury to or the death of one or more persons, and for loss or damage to property, regardless of the number of claims arising from any one accident / $ / $
Section B
Loss of or damage to owned automobiles / S
U
B
S
SE
C
T
I
O
N
S / 1* / All perils / Deductible per occurrence except
for loss or damage by fire or lightning. / $ / $
2* / Collision or upset / $ / $
3* / Comprehensive (excluding collision or upset) / $ / $
4* / Specified perils / $ / $
Section C
Civil liability for loss of or damage to customers’ automobiles while in the care, custody or control of the Insured / 1* / All perils / $ / $ / $
2* / Collision or upset / $ / $ / $
3* / Comprehensive (excluding collision or upset) / $ / $ / $
4* / Specified perils / $ / $ / $
* / Under Section B, except with respect to collision or upset, the premium shall be computed on:
a monthly average basis / a 100% co-insurance clause basis / another basis: ______
Under Section C, except with respect to collision or upset, the premium shall be computed on a 80% co-insurance clause basis.
Endorsements: QEF no 4-19 – Section B - Limitation of amount endorsement, QEF. no 4-70 – Excluding owned automobiles endorsement
Premium due date: / Advance premium / $
Final premium
ITEM 5 – Where the premium is an advance premium only, the basis of rating and calculation ofthe premium shall be as stated in endorsement Q.E.F. no 4-79a, Premium Computation Statement, attached hereto.
ITEM 6 – Important statements for underwriting the risk
The information declared herein and in the annexed document entitled EMERGENCY SERVICE & TOWING ORGANIZATION SURVEY constitutes a declaration of utmost importance for the appraisal of the risk.
ITEM 7 – Notice (read carefully)
Any misrepresentation or deceitful concealment on the part of the applicant in connection with facts known to it and likely to materially influence a reasonable Insurer in the setting of the premium and the appraisal of the risk or the decision to cover it, nullifies the contract at the instance of the Insurer, even for losses not connected with the risks so misrepresented.
Date: Signature of applicant: Title:

THIS APPLICATION MUST INCLUDE THE EMERGENCY SERVICE & TOWING ORGANIZATION SURVEY FORM DULY COMPLETED AND SIGNED.

4405, boulevard Lapinière, Brossard (Québec) J4Z 3T5 – Tél: 1-877-745-2020 – Fax: 450-672-8012

- www.april.ca

APRIL Canada Inc. Towing Application (March 2016)

EMERGENCY SERVICE & TOWING ORGANIZATION SURVEY
Reference No or Policy No:
Broker:
1.  Name of applicant (including all subsidiaries):
2.  Main address: / Telephoneno:
Fax no:
Name of the Owner:
3.  Address of the garage where the vehicles are stored:
Number of vehicles inside: / Number of vehicles outside:
Construction of building:
Other(s) operation(s):
Protection – Fire:
Protection against theft:
4.  Type of business / Towing only / Emergency service and towing organization / of light-weight vehicles / of vehicles weighing over 4500kg
Common carrier / Private carrier
Indicate % of your activities: / Emergency service and/or towing / %
Carrier / %
5.  SAAQ Identification number (NIR): / R- / As: / operator / solely as owner / intermediaries
6.  Number of years in business under this name:
7.  Has the applicant any other insurance for other commercial vehicles not included in this proposal ? / Yes / No
If yes, please explain:
8.  Are all vehicles registered under the name of the applicant and in the province of said applicant ? / Yes / No
If no, please explain:
9.  Are any vehicles rented, leased or loaned to others ? / Yes / No
If yes, please explain:
10.  If subcontractor (owner only), name of employer(s):
11.  Is the applicant part of a group or is he franchised? / Yes / No
If yes, please explain:
12.  Is the applicant holding exclusive contracts for certain routes or sectors? / Yes / No
If yes, please explain:
13.  Does the applicant store towed vehicles in places other than the above-mentioned address? / Yes / No
If yes, please state the address:
Number of vehicles inside: / Number of vehicles outside:
Construction of building:
Other(s) operation(s):
Protection – Fire:
Protection against theft:
14.  Provinces and States requiring filings: / ICC No / MC-
US DOT No
15.  Radius of operation: / Please write down the percentage of the total mileage for each region or radius and enclose a fuel tax report.
Region / 0 – 100 km (%) / 101 – 300 km (%) / 301 – 500 km (%) / 501 – 900 km (%) / 901 km and more (%) / Total (%)
Québec
Ontario
Others – Canada
United States
Total
16.  Please list major cities, as well as the States and Provinces where the vehicles are operating:
17.  Safety program? / Yes / No
18.  Transported goods: Please declare average and maximum values
Description / % / Average ($) / Maximum ($) / Description / % / Average ($) / Maximum ($)
Are any vehicles used to carry the following products ? Yes No
If yes, please give a description of the product and whether in full or partial loads:
Dangerous goods
UN number: / Yes / No / Recreational vehicles, boats / Yes / No
Dangerous waste / Yes / No / Refrigerated products / Yes / No
Tobacco, fur / Yes / No / Aluminum, copper, zinc, stainless steel / Yes / No
Computers, electronics / Yes / No / Drugs / Yes / No
Alcohol, beer / Yes / No / Oversize / Yes / No
Does the applicant carry any merchandise belonging to him? / Yes / No
If yes, please explain:
Represent which percentage of the total cargo? / %
19.  List of drivers
Name / Start date / Licence no / Demerit points / Years of experience Emergency & Towing / Suspension or revocation
20.  List of vehicles: / (actual value and address of mortgagee or lessor)
Year / Make / Serial number / Actual value / Mortgagee ( M )
Lessor ( L ) / Address of Mortgagee or Lessor
$
$
$
$
$
$
$
$
$
21.  Loss experience: / (Automobile, Garage Liability, CGL and cargo for the past three (3) years with a brief description of each occurrence.)
Date / Type / Payment / Reserve / Closed (C)
Opened (O) / Brief description of each occurrence
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
22.  Coverage required: / (Take note the Insurer does not undertake to give the above-requested coverages)
Civil Liability / Amount / Deductible
Section A – Automobile / $ / $ / Property damage (QEF no 8)
Commercial General Liability / $ / $ / Property damage (min. $1, 000)
Anticipated revenues / $
Tenants Legal Liability (not included) / $ / $ / (minimum $1,000)
Truckmen’s Cargo Liability / $ / $
Amount per terminal / $ / $
Catastrophic Limit / $ / $
Damage to towed vehicles
Subsection C2 – Collision or upset / $ / $
Subsection C3 – Comprehensive / $ / $
Damage to Insured’s vehicle(Section B of the Garage Policy No. 4)
Subsection B2 – Collision or upset / $ / $ / (minimum 5% ou $1,000)
Subsection B3 – Comprehensive / $ / $ / (minimum 5% ou $1,000)
QEF no 4-19 and QEF no 4-70 included
Cargo insurance, own form
/ $ / $
Other(s) coverage(s) requested
Are the coverages requested, the current coverages? / Yes / No
If no, please explain:
23.  Previous insurers: / Please include claims experience of the last three years on the paper of the insurer.
Q.P.F. no 4 / CGL / CARGO
Term / Insurer / Insurer / Insurer
Policy No / Policy No / Policy No
Term / Insurer / Insurer / Insurer
Policy No / Policy No / Policy No
Term / Insurer / Insurer / Insurer
Policy No / Policy No / Policy No
24.  Has any insurer, to the knowledge of the applicant, cancelled, declined or refused to renew an automobile, garage, cargo insurance or civil liability?
Yes / No
If so, please state the name of the Insurer(s) and the reason ?
25.  Please give particulars of all convictions or suspension of permit under the Highway Safety Code or Criminal Code issued against the applicant or, to his knowledge, his representatives, his employees during the past three (3) years.
26.  Comments:
Date: / March 17, 2016
Broker’s Signature / Applicant’s Signature:

4405, boulevard Lapinière, Brossard (Québec) J4Z 3T5 – Tél: 1-877-745-2020 – Fax: 450-672-8012

- www.april.ca

APRIL Canada Inc. Towing Application (March 2016)