Online Application

SEEDSMENS ERRORS AND OMISSIONS APPLICATION FORM
For Members of ISF/CSGA – CANADIAN SEED GROWERS ASSOCIATION

(This Application Form is for a Claims Made Policy)

1. Applicants Name:

Contact Name:

Phone Number:

Fax Number:

Email Address:

Address of Head Office:

City:
Postal Code:

Province:

2. Address(es) of Branch Office(s), if any:

3. Date established or incorporated:

4. Is the Applicant controlled, owned or associated with any other firm, corporation or company?

Yes: No:

If Yes, please explain:

Are any sales of seed provided to, or from, such parent or associated companies?

Yes: No:

If Yes, please explain:

5. Of which Seed Trade Association(s) is the applicant a member in good standing?

ISF: CSGA: CSTA: | Other:

6. Is the Firm a co-operative, or a member of a co-operative?

Yes: No:

7. A) Does the firm research or develop Genetically Modified seed varieties (GMO)?

Yes: No:

B) If “Yes” are new GMO seed varieties test grown for a minimum of 2 growing seasons before being marketed?

Yes: No:

C) If 7(b) is “No”, please explain procedures to ensure the GMO seed variety is of the required quality and has the required characteristics.

8. Do you use a standard disclaimer and/or limited remedy clause on all your seed tags, bags, labels and invoices, limiting your liability to replacement, or the cost of replacement, seed?

Yes: No:

If "No" please explain

9. Please give the CAD Sales for the last 12 months:

Type of Seeds:
Domestic Sales:
Export Sales:
(non-USA)
USA Sales:
Agricultural
Vegetable

B) Please list main types of seed:

Agricultural:
Vegetable:

C) Please list Countries to which you export seed:

D) Please give approximate percentage of your sales from:

Seed grown by you or by others for you:
%

Seed grown under contract without responsibility for quality control:
%

Treating/Conditioning seed for others:
%

Distribution of seed grown by others and sold under their labels:
%

i) Please give the approximate value of any one Lot of seeds:

Average:
Maximum:

ii) To how many customers do you usually expect to sell any one Lot of Seed?

10. A) Do you deal in Green Bean Seeds?

Yes: No:

If “Yes” advise the source of Green Bean Seeds:

B) Do you deal in Watermelon Seeds:

Yes: No:

If “Yes” please advise the measures taken against Watermelon Fruit Blotch:

11. Do you comply with:
A) ISF Guidelines on the Prevention and Handling of Claims in the Seed Industry?

Yes: No:

B) Internationally accepted procedures for seed testing such as AOSA or ISTA?

Yes: No:

12. Have you initiated an ISO 9000 Program?

Yes: No:

13. In testing and checking seeds, does the firm maintain a private laboratory staffed with a senior analyst?

Yes: No:

If “No” does the firm use the facilities of a qualified commercial laboratory?

Yes: No:

Please name the laboratory used:

14. Has any application for Errors and Omissions Insurance made on behalf of the Applicant to the knowledge of the Applicant or on behalf of their predecessors ever been declined or has any such insurance ever been cancelled or renewal refused?

Yes: No:

If “Yes”, please give full particulars:

15. Have any claims been made during the past five years against the Applicant or their predecessors in business that would have been covered by the proposed insurance?

Yes: No:

If “Yes”, please give full particulars:

16. Is the Applicant aware of any circumstances which may result in a claim being made against the firm?

Yes: No:

If “Yes”, please give full particulars:

17. Do you currently carry Seedsmens Errors and Omissions Insurance?

Yes: No:

If “Yes” please give full particulars:

Insurer

Sum Insured

Deductible

Premium

Period

Retroactive Date

18. Amount of Indemnity required (CAN):

250,000 500,000 1,000,000 2,000,000 5,000,000
Other:

Amount of Self-Insured Retention required:

2,500 5,000 10,000 25,000 50,000 100,000
Other:

PRIVACY CONSENT: Effective January 1, 2004 provincial legislation requires that all insurance brokerages comply with the Personal Information and Electronic Documents Act (PIPEDA). The purpose of this act is to protect your right of privacy and to safeguard personal information that you give us. This act does not change the current practices and procedures that we have in place for conducting business with you. It is necessary for us to obtain personal information from you in order to provide quotations, issue insurance policies, report claims on your behalf, and assess your ongoing needs for other insurance and financial products that we may be able to offer you. Many of these procedures involve the disclosure or relay of information to a third party such as: insurance companies, lawyers working on your behalf, adjusters who may handle your claim, or simply inter-office communication between our personal and commercial divisions. Although our procedures are unchanged, PIPEDA does now require that we obtain your consent regarding the collection, use and disclosure of your personal information. By signing this application you are providing consent to the statements above. Please note that you may withdraw your consent at any time, but in doing so may hinder or possibly even prevent our ability to work on your behalf. To view Dalton Timmis’ Privacy Policy, please visit www.daltontimmis.com.

DECLARATION: I/we hereby declare that the above statements and particulars are true and that I/we have not suppressed or misstated any material facts and that I/we agree that the application form shall be the basis of the contract with underwriters. However, it is expressly understood and agreed that this application does not provide coverage or bind hereunder in any way nor to any extent whatsoever for any loss or claim and completion of this application is for quotation purposes only.