Underwriting Alliance Group

New Submissions (Totten): [email protected] New Submissions (Travelers Canada): [email protected]

RESTAURANTS CANADA INSURANCE APPLICATION

The Totten Insurance Group Inc. and/or The Dominion of Canada General Insurance Company (now part of Travelers Canada) (the “Underwriters”) will rely upon each and every response given in this Proposal Form and any Supplementary Proposal Form in deciding whether or not to insure this risk and if so at what premium, terms and conditions. Underwriters regard every response to be material to their decisions. Failing to answer or answering any question below incorrectly could invalidate any policy of insurance written by the Underwriters for this risk. We have a professional duty of confidentiality and are committed to holding personal information in strict confidence. The information provided to us will only be disclosed where required by law or where required to conduct negotiations with third parties, such as insurance companies, on your behalf. We will further safeguard the security of such information in a manner appropriate to sensitivity of that information.

GENERAL INFORMATION

Is insured a Restaurants Canada member in good standing? Yes No Membership number: Brokerage name: Broker contact name: Phone: Fax: Named insured (Full legal name):

Principals name(s): Phone number:

Risk address: Postal code:

Mailing address: Postal code:

Insured’s web site address: Email address: Is insured a member of a franchise group: Yes No If yes, provide name: Description of operations (check appropriate box): Pub/Sports bar Fine dining restaurant Lounge/Night club Private club Family restaurant Concert hall Seasonal Mobile operation Hotel/ Motel Adult entertainment Banquet hall Other If other, please describe: # of Room rentals, if any: If “Private Club” or “Other” is selected please provide a list of activities and attach to this application Are there any bouncers: Yes No Name and address of mortgagees: 1. 2. Existing insurer: Expiry date:

Expiring Premium: $ Policy #:

Renewal terms being offered? Yes No If no, reason for non-renewal:

Has the insured been cancelled / declined insurance (including boiler)? Yes No (If yes, please attach details i.e. reason)

Previous losses: Yes No (5 years – please attach full details, date, payments, reserve, cause, class, open/closed, etc.)

Number of years the insured has been in business at this location: Prior operating experience / number of years at other locations: If other locations, name of business and address of location(s) to enable an experience credit to be applied:

Have you incurred any provincial liquor control board violations and/or suspensions in the past 5 years? Yes No Page 1 of 4 April 2014, Hospitality.doc Has the liquor permit been suspended or revoked during the past 5 years? Yes No (If yes, please attach details)

Does the insured engage in rental of location for special functions (i.e. weddings, banquets, etc)? Yes No If yes, number of times per year? PROPERTY SECTION

Building Construction: Roof: Concrete Steel Wood Other (describe)

Walls: Concrete Steel Wood Other (describe)

Floors: Concrete Steel Wood Other (describe) Additional description:

Heating Type: Forced Air Natural Gas Yes No Oil Yes No Electric Yes No Other

If heating type is oil: Location(s) of tank? Age of tank: If Electrical, type: Fuses Circuit Breakers Year updated: Full or partial Roof Heating Electrical Plumbing Year building built: Total number of stories in building: Total sq. ft. of building: Occupancy: 1st Floor Sq. ft 2nd Floor Sq. ft 3rd Floor Sq. ft Other Sq. ft If other, describe:

Insured is: Owner Tenant If Tenant, landlord’s name:

Are you responsible for building insurance/snow removal? Yes No Total sq ft of all floors occupied by the business (incl basement)

Is a log kept? Yes No Certificates of insured obtained? Yes No

Is premises sprinklered? Yes No % Sprinklered: Distance to hydrants: ft. Firehall: mi.

Is there an alarm system connected for fire detection? Yes No

Is the kitchen equipped with: Deep fat fryer Grill (hot plate)

Is there an Automatic Extinguishing System in the kitchen: Yes No Wet system Dry system

Is there a 6 month maintenance contract in effect? Yes No Automatic extinguishing system maintenance company: Are kitchen grease traps cleaned and serviced regularly? Yes No If yes, frequency? Is there a wine/spirits inventory tracking/checking system? Yes No Please provide details e.g. electronic/paper (if paper is there a back-up copy) and frequency of inventory tracking/checks:

Any temperature control equipment /rooms for storage of wine: Yes No If yes, are they alarmed/monitored: Yes No Provide details of protection:

Is there a back-up power source for the temperature control equipment: Yes No

Sewer Back-up: Any instances of sewer back-up over the past 5 years? Yes No If yes, please provide details:

Water Main/Supply: Is the Applicant/Tenant/Staff aware of and have access to the shut-off valve? Yes No Have the small tanks been replaced within the past 10 years? Yes No N/A

Central Hot Water or Steam Heating: Is proper drainage provided for the boiler room? Dyking? Floor drain? Yes No N/A If no, comment on steps being taken to avoid water damage loss:

Leakage from Appliances: Are appliances connected with braided hoses? Yes No N/A

Sump Pump(s): Is there a sump pump? Yes No N/A Is there a supervised alarm for the sump pump? Yes No N/A

CRIME SECTION Alarm System: Local Monitored Make of alarm: Monitoring company: Safe make: Safe class: Safe dimensions: Frequency of bank deposits: Deposited by whom:

(Totten Group *Overnight coverage is limited to $250.00 unless contained in a minimum class II safe*

of 4 April 2014, Hospitality.doc Travelers Canada *Overnight coverage is limited to $2,000.00 unless contained in a minimum class II safe*)

of 4 April 2014, Hospitality.doc LIABILITY SECTION Licensed capacity: Pub/Sports bar: Restaurant: Private club: Night club: Adult entertainment: Roof top patio, ground level, other Hotel/Motel: Other (describe): Total # of rooms licensed: Number of employees: Full time: Part time: WCB: Gross Receipts: Food: $ Liquor: $ VLT’s: $ /# Cover charges: $ Liquor store Receipts: $ Other: $ Total receipts: $ Liquor receipts should not include beverage mix (pop), coverage charge, coat checks, etc. Include in other. Describe other: Hours of operation: From: To: # Days open: Security personnel / Bouncers: In-house: Sub-contracted: # of security personnel: How are patrons evicted from premises? Under what circumstances are police called?

Is the I.D. checked on all patrons that could potentially be underage? Yes No If customers become intoxicated, how are they handled?

Is service of alcohol stopped? Yes No Will staff contact a taxi? Yes No

Have managers/servers taken S.M.A.R.T. program or equivalent? Yes No

Does your establishment have a staff training program? Yes No

Have you ever had any food or health violations? Yes No If yes, please explain:

Do you maintain an incident log? Yes No Entertainment/Activities: Description Nights/ week Description Nights/ week Comedy Dance floor Square footage of dance floor Disc jockeys Exotic dancers Karaoke Live band Types of music:

(1) All ages/under age raves and events: Yes No

(2) Mechanical bulls: Yes No What is the search protocol for patrons entering the premises?

Applicant Declaration Consumer and previous insurer reports containing personal, credit, factual or investigative 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. Should a policy be issued through Totten Insurance Group or The Dominion of Canada General Insurance Company, now part of Travelers Canada, the policy may be deemed to be void and claims may be denied where: 1. An applicant for a contract: a) gives 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 wilfully 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 STATEMENTS. I AM IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE CONTRACT BETWEEN THE TOTTEN INSURANCE GROUP INC. OR THE DOMINION OF CANADA GENERAL INSURANCE COMPANY AND MY BUSINESS. SIGNATURE OF DATE: APPLICANT: TITLE: PRINT NAME:

COVERAGES AND LIMITS REQUESTED (if more than one location attach additional information/pages) SECTION 1 - PROPERTY- Location # Building #

Address As noted on page #1 or

of 4 April 2014, Hospitality.doc Form Named perils Broad form Valuation Actual cash value Replacement cost Deductible $2,500 Other Limits Building $

Contents $

Office contents $ Stock $ Wine or spirits $ Enhanced replacement cost limit requested $ Computer protection - equipment $ Business income $ Ordinary payroll “25% of business $ income limit” OR Extra expense $ Rental income $ Miscellaneous form $ attach schedule Satellite dish $ Sign $ Extensions Earthquake Flood Sewer backup SECTION - CRIME Comprehensive dishonesty, Disappearance and Destruction Employee dishonesty form A $ Loss inside the premises $ Loss outside the premises $ Money orders and counterfeit paper $ currency coverage Depositors forgery coverage $ Credit card forgery $ SECTION - LIABILITY Form Occurrence Deductible $1,000 Other $ Property damage Other: $ Limits Commercial general liability limit: $ Tenants legal liability limit: $ Non- Is there fast food delivery Is non-owned auto coverage required? Yes No Owned excluding catering events? Yes No If yes, are drivers employees: Yes No Auto Are autos owned: Yes No Provide minimum age of drivers: Do drivers use own vehicles? Yes No Do you confirm valid insurance with min. 2MM TPL limit? Yes No Do you request MVR’s from drivers? Yes No

SECTION – MACHINERY BREAKDOWN Property damage $ Gross rentals $ (if provided in Section 1above) Business income $ (if provided in Section 1above) Ordinary payroll - 90 consecutive days $ Consequential damage $25,000 Limit Advise if higher limit required $

This document is provided for informational purposes only. It does not, and it is not intended to, provide legal, technical or other professional advice, nor does it amend, or otherwise affect, the provisions or coverages of any insurance policy or bond issued by The Dominion of Canada General Insurance Company, St. Paul Fire and Marine Insurance Company or Travelers Insurance Company of Canada and their subsidiaries and affiliates (collectively “Travelers Canada”), nor is it a representation that coverage does or does not exist for any particular claim or loss under any such policy or bond. Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions and any applicable law. Travelers Canada disclaims all warranties whatsoever.

of 4 April 2014, Hospitality.doc