SAWMILL APPLICATION FORM

Name of Insured:

Mailing Address:
(Incl. Post Code) 

Location Address:
(Incl. Post Code) 

Number of Years in Business:

Type of Products:

Full Details of Processing Procedures and Hazards:

Financials
Annual Gross Receipts: $

Please provide the following –

a)	Last three months financial results:

b)	Financial results from the same three months last year:

c)	Volume of orders for the next six months:

Construction

Construction and age of each building on the site:

Separation of buildings: (please provide site plan)

Separation of stock from nearest building:

Fire Protection:

i)	Public: (Is Fire Dept Full Time or Volunteer and distance and approx response time )

Fire Dept – Full time or Volunteer? 

Distance from mill site?  

Approximate response time? 

Has mill been visited by the Fire Dept? 

ii)	Private: (including private water supplies, sprinklers, fire extinguishers etc.)

iii)	Hydrants:

Housekeeping:

Debris Removal –

i)	How?

ii)	Frequency?

If this is a reman Mill, is there a dust collection system?

If yes, please provide full details:

How often is sawdust accumulation swept and/or cleaned?

How many employees work on the premises?

How many employees worked at this time last year?

Are the employees full-time?

How many days per week is the operation running?

How many hours is each shift?

Smoking regulations:

Hot Work / Welding and Maintenance 
(Hot Work is defined as any work using open flames or sources of heat that could ignite materials in the work area e.g. Welding, Burning, Brazing, Propane Soldering, Oxyacetylene cutting, grinding ferrous metals.)    

Is a Hot Work Permit system in place?  

Hot Work / Welding on site –

i)	Who does it?

ii)	How often?

iii)	Procedures? Please describe actions taken: -   

a)	Before Hot Work

b)	During Hot Work 

c)	After Hot Work

Is there a permanent location designed or approved for Hot Work operations (such as a maintenance shop or detached outside location) that is of incombustible or fire resistive construction, free from combustible and flammable contents and segregated from adjacent areas?   

Do third party welding contractors carry a CGL with a minimum limit of $1,000,000?

How often is routine maintenance carried out on the equipment?

Describe routine maintenance procedures:

Burner

Is there a burner on site, and if so, what is the separation from the building/stock?

Is the burner used?

Wiring

Wiring on circuit breaker?

When was the wiring last updated?

Flood 

Has there been any history of Flood at this location(s)? 

Previous Insurance

Existing Insurer                                                     Expiry Date:  

Will they renew? 	

If no, give reason for non-renewal 

Expiring premium, coverage terms and conditions: 

•	Statement of values – Please attach						    CAD

Building(s) 
	
Equipment (Please Schedule)
	
Stock 
	
Contents
	
Mobile Equipment (Please Schedule)
	
Profits 
	
Gross Earnings 
	
Extra Expense 
	
Rental Income 
	
Office Equipment 
	
Other (specify) 
	
Other (Specify) 
	
TOTAL INSURED VALUES

•	5-year loss history – Please attach with full details

Are there any outstanding loans or mortgages against the property?

If yes, please provide details of amounts and time remaining on the loan(s):

Insured’s Signature						Date

SAWMILL INSPECTION AND APPLICATION FORM
TO BE COMPLETED BY THE BROKER

How long have you known the insured?

Have you personally inspected the risk?

How do you rate the risk for its class? (Check one)	     Excellent	   Good         Fair           Poor

Do you consider the insured to be financially sound?

If yes, please provide details to support your opinion:

Broker’s Signature						Date

Agency: