MONEY LENDING & CHEQUE CASHING APPLICATION

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GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 1 of 7

MONEY LENDING & CHEQUE CASHING APPLICATION

BROKERAGE:

Broker contact: Phone No.:

Email address: Fax No.:

INSURED: Individual Partnership Corporation Joint Venture

Full Legal Name: Operating Name: Mailing Address: Risk Location: Principal Owner:

Has the principal or any active partner filed for bankruptcy? Yes No If yes, provide details: Loss Payee / Mortgagee / Additional Insured (include address below):

1. 2.

INSURANCE EXPERIENCE: New Business Renewal Are you incumbent broker? Yes No

Existing Insurer: Target Premium Required:

Renewal Offered: Yes No If not, why?

Have you had any insurance refused or cancelled within the past 5 years? Yes No If yes, please explain:

LIST OF ALL LOSSES OR CLAIMS (Whether or not Insured – Sustained during Past

5

Years on all operations):

Date of Loss Details of Loss Amount Paid/Reserve Open/Closed

Describe any insured and uninsured losses which have occurred in the past 5 years and state the date, type and value of each loss before the deductible (if any) was applied:

If previous losses/claims have occurred, please advise the steps taken to prevent a re-occurrence?

45 Vogell Road, Suite 306,

Richmond Hill, Ontario L4B 3P6

Tel: 905-305-0852

Toll: 1-888-489-2234

Fax: 905-305-9884

www.grouponeis.com

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Operating Experience:

New Venture: Yes No If yes, prior experience in this industry:

Years in Business: Years of Current Ownership: Years at this Location:

List & describe any business owned, operated, or managed by the Insured:

Is the Insured a subsidiary of any other identity or does the Insured have any subsidiaries? If yes , please explain:

Occupied by Applicant as: Occupied by Other as:

Any portion of this building: Vacant or Unoccupied? Yes No Under Renovation? Yes No If yes, please explain:

COVERAGE REQUESTED

Section 1 – Property Section 2 – Crime

Section 3 – Commercial General Liability Section 4 – Boiler SECTION 1 - PROPERTY

LOCATION # 1

Year Built: Number of Stories:

Total Area: sq ft Area Occupied By Insured : sq ft Occupies Basement? Yes No

Structure

Type: Industrial Plaza Strip Plaza Stand-Alone Building Commercial/Residential

Commercial Condo Other:

Walls: Frame Brick Veneer Masonry HBC Non-Combustible

Stucco Alum. Siding Fire Resistive Others:

Floor: Concrete Wood Joist Wood Others:

Roof: Wood Joist Steel Deck Concrete Patent Others:

Fire

Protection: Fire hydrant within 300 metres/1000 feet Fire Hall within 8km Unprotected Paid Volunteer Distance to Responding Fire Department:

Sprinklers: Yes __ % No Smoke Detectors: Yes No Heating: Gas Electric Oil Combination Furnace Wood Stove Other:

Electrical: Fuses: Circuit Breakers:

Updates: Heating: Plumbing: Roof:

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GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 3 of 7

SECTION 2 – CRIME

Number of Employees: Managers Full Time Part Time

Are employees bonded? Yes No Do Employees undergo police checks? Yes No

Gross Annual Payroll: How often are Police checks done?

Protection: Burglar Alarm: Central Station Monitored Local None Rated: ULC CSA

Full Perimeter Partial Perimeter Contacts : All Windows All Doors

Motion Detector Heat Detector Other:

CCTV in place Yes No Number of Cameras:

Procedure involving CCTV?

Monitoring Company: Percentage protected: %

Dedicated line: Yes No Connected for fire detection: Yes No

Safe: Yes No Safe Make: Safe Class:

(must be provided)

Metal bars on all windows & doors: Yes No Are all doors fitted with deadbolts? Yes No

How Often are bank deposits made? By Whom:

*If cash advance operation, separate questionnaire must be completed. SECTION 3 – COMMERCIAL GENERAL LIABILITY

Sales/Receipts: $ Canadian $ USA $ Other

GROSS RECEIPTS DECLARATION:

Annual Gross Receipt Projected Gross Receipt

Cheque Cashing $ $

Money Transfer Service $ $

Sale of Stamps, Tokens or Ticket $ $

Gold & Silver Exchange $ $

Currency Exchange Service $ $

Pay Day Loan Services $ $

Sales of Phone Cards $ $

Mail Box Rentals $ $

Tobacco Related Sales $ $

Other: (Details) $ $

Other: (Details) $ $

Other: (Details) $ $

Total Receipts: $ $

Are all employees covered by Worker’s Compensation? Yes No

Do you maintain an incident log? Yes No

Are Certificates of Insurance required? Yes No

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SECTION 4 – BOILER INSURANCE/MECHANICAL BREAKDOWN

Is the coverage required? Yes No

LIMITS OF INSURANCE

Coverage – Broad Form Named Perils Deductible Co-Ins Limit of Insurance

Building(s) ACV RC 80%/90% $

Contents ACV RC 80%/90% $

Equipment ACV RC 80%/90% $

Stock ACV Only 80%/90% $

Office Equipment 80%/90% $

Electronic Data Processing Equipment 80%/90% $

Profits 100% $

Gross Earnings 80% $

Extra Expense - $

Rents or Rental Value Form 100% $

Sign Form 100% $ 10,000

Glass Rider - $ Blanket

Sewer Back-Up $ 10,000

Earthquake Yes No $100,000 3% or $ Included

Flood Yes No $50,000 $ Included

Valuable Papers and Records - $ 10,000

Accounts Receivable - $ 10,000

Newly Acquired or Constructed Buildings $ 1,000,000

Newly Acquired Business Personal Property $ 500,000

Fire Department Service Charges $ 20,000

Peak Season Endorsement $ 25,000

Personal Effects $ 5,000

Property Off Premises $ 10,000

Property In Transit $ 10,000

Damage to Building by Theft $ 5,000

Professional Fees $ 25,000

EDP Equipment, Data and Media $ 25,000

Conviction Reward $ 5,000

Employee Dishonesty - $

Broad Form Money and Securities - $

Loss Inside the Premises - $

Loss Outside the Premises - $

Safe Burglary - $

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GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 5 of 7

Third Party Computer and Funds Transfer Fraud - $ Included

Incoming Cheque Forgery $ Included

Credit Card Forgery - $ Included

Liability – Commercial General Liability – Occurrence Form - $

Aggregate Limit – Products and Completed Operations $

Medical Payments -

$ 10,000 Per Person $ 10,000 Per Occurrence

Personal Injury - $

Advertising Injury - $

Tenant’s Legal Liability - $ 250,000

Non-Owned Automobile – SPF #6 - $

S.E.F. #99 Excluding Long Term Leased Vehicles Endorsement

Boiler Insurance 80%/90% $

Mechanical Breakdown 80%/90% $

BROKER DECLARATION

Is this account NEW to your office? Yes No If no, how long have you known the applicant?

Is the applicant financially sound? Yes No Have you personally seen this property? Yes No

Do you recommend this applicant? Yes No Is the property for sale? Yes No

Comments:

I/We hereby declare that the statements and particulars contained in this application are true and that I/we have not

suppressed or mis-stated any material facts and I/we agree that should a policy be issued then this application shall be the basis of the contract with Underwriters.

This application must be signed by the Producer/Account Executive.

Signature of Producer/Account Executive: Date:

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DISCLAIMER

Consumer and previous insurer reports containing personal, credit, factual, or investigate information about the applicant may be sought in connection with this Application for insurance or any renewal, extension, or variation thereof. All provisions contained in the various forms issued under this contract shall be deemed to be contained in the present Application of insurance.

The policy may be deemed to be void and claims may be denied where: 1. An applicant for a contract:

a) Provides false or erroneous information to the prejudice of the insurer; or

b) Knowingly misrepresents or fails to disclose in the Application any fact required to be stated therein; or 2. The insured contravenes a term of the Contract or commits a fraud; or

3. The insured willfully makes a false statement in respect of a claim under the Contract.

I CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND ACCURATE AND APPLY FOR A CONTRACT OF INSURANCE BASED UPON THE TRUTH OF THE STATEMENS.

I AM IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE CONTRACT BETWEEN THE INVOLVED PARTIES.

Signature of Applicant: Date:

Title of Applicant:

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GroupOne Insurance Money Lending & Cheque Cashing Application Form (2014) Page 7 of 7

MONEY LENDING SUPPLEMENT

CRITERIA

1. The doors between the “secured area” tellers’ room and client service area have “deadbolt” locks

which can only be opened by authorized personnel? Yes No

2. The division wall between the “secured area” and client service area floor to ceiling, either the actual building ceiling or a drop ceiling with the service area counter being constructed of bullet proof glass surrounded by steel framing?

Yes No

3. Employees are given specific instruction as to their duties in the event of hold-ups and as to the

measures to be taken to prevent, control or minimize loss from such incidents? Yes No

4. Each teller has a separate cash drawer and separate working fund? Yes No

5. Each teller’s drawer is reconciled at the end of each shift? Yes No

6. There’s a “ULC” certified alarm system, covering the perimeter, and all doors, windows & skylights, and motion detectors covering the “secured area” and client service area and is it connected and in working order?

Yes No

7. There’s a UL or ULC listed Class 2, “TR-15” or better safe located on the premises, and is located

within the “secured area”? Yes No

8. There’s an inspection of the exterior of the premises for signs of forced entry? Yes No

9. Panic Button on Premises? Yes No

10. CCTV on Premises? How many Procedure in place: Yes No

11. Is there an audit and control procedures manual? Yes No

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Is there an incident report manual on premises?

Yes No

13.

The person responsible for auditing has the authority to check any person and record at any

time?

Yes No 14.

A plan exists for the periodic “surprise” testing of internal control systems under the

supervision of the person responsible for auditing, and are all discrepancies reported directly

to the owner as soon as practical?

Yes No

15.

A hired guard/armored motor vehicle service is not used in the transferring of money &

securities? Are trips scheduled at irregular intervals and over varying routes?

Yes No 16.

Is there a rule against cashing cheques bearing rubber stamp signatures?

Yes No 17.

Cheques in excess of a specified amount require approval of a supervisor before being

cashed?

Yes No

18. Will there ever be only one staff member on premises at any give time? Yes No

19. How many employees are working at any given time? Average #

With respect to items presented above:

• “Secured Area” means an area within the insured location where money & securities are retained. • “Money” means currency, coins, banknotes, bullion, gold & silver jewellery

• “Securities” means negotiable and non-negotiable instruments or contracts representing either money or other property and includes revenue and other stamps in current use, tokens and tickets but, does not include “money”.

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