 |
| Legal Name of Affiliate
Club |
Membership Number |
|
|
|
| Premises Address |
City |
|
|
|
| Province |
Postal Code |
| |
|
| Mailing Address |
City |
|
|
|
| Province |
Postal Code |
| |
|
| Contact Name (Last,
First) |
Email |
|
|
|
| Telephone |
Fax |
|
|
|
| How many members does
your club have? |
|
|
| Please Describe in
detail all activities your club is involved in during a typical
club year and whether these events are organized by your club
or if your club is merely a participant (e.g. parades, field
demonstrations, banquets, etc.) |
|
|
 |
| Current Insurance Carrier |
|
|
| Policy Expiry Date |
Policy Number |
|
|
|
| Losses in the last 5 years |
|
|
 |
| Mortgagee (if any)
and mailing address(es) |
|
|
| Requested Effective Date
for Coverage |
|
DD/MM/YY |
| Fire Hydrants Within |
Local Fire Hall Type |
|
ft. |
Volunteer
Full-Time |
| Name of Nearest Responding
Firehall |
|
|
| Distance from Nearest
Responding Firehall |
|
km |
Total replacement value
of all property owned by the club, including
office and radio equipment, computers, premises improvements
made by you |
|
|
| Antennas and towers |
Total Cash Value |
| $
|
$
|
| Is Inventory kept in a
safe place? |
Is a copy of the Inventory
kept off premises? |
|
yes
no |
yes
no |
| Do you rent space? |
If renting, what sq. ft.
of
premises do you occupy? |
|
yes
no |
sq. ft. |
| Age of Building |
If over 30 years, when
were wiring and heating updates done? |
|
|
|
| Construction of building |
|
Frame
Solid Brick
Fire Resistive |
| Are there other occupancies in the
building? |
To the Right
To the Left
Behind
|
 |
| Alarms |
• Fire alarm
Monitored
Local
• Intrusion Alarm
Monitored
Local |
| Number of Fire Extinguishers |
Type of Fire Extinguishers |
|
|
|
| Deadbolt? |
Barred Windows? |
|
yes
no |
yes
no |
| Sprinklers? |
|
|
yes
no |
|
 |
| It is hereby warranted
that all equipment and antennas to be insured are protected
by power surge and lightning arresters meeting or exceeding
the following specifications.
Definitions
- All connections between equipment and the grounding
electrode shall not be smaller than No. 10 copper or No.
17 copper-clad steel conductors
- All masts and metal structures supporting antennas shall
be permanently grounded using an adequate grounding electrode
- Each conductor of the feed line from an outdoor antenna
shall be provided with a lightning arrester equal to or
exceeding the Cushcraft Lac-4 series lightning arresters;
unless the feed line conductors are enclosed in a continuous
metallic shield, in which case the lightning arrester
may be omitted from the shield if the shield has been
grounded by adequate grounding electrodes
- The ground terminal of all equipment connected to an
external antenna shall be permanently grounded using an
adequate grounding electrode
- All connections between telephone lines and equipment
shall be made through a modem surge suppressor filter
- It is understood and agreed that benefits under this
policy, shall be reduced by the following, should the
conditions of this warranty not be met
- 50% of the replacement cost of the property insured
hereunder, where replacement of such property applies,
or
- 50% of the actual cash value where such property
is obsolete, as defined
"Adequate grounding electrode" shall mean an
electrode which has a resistance to ground measured at a
frequency less than 400 HZ of less than 25 ohms, by using
a 3 meter long copper rod driven into the ground at a maximum
angle of 45 degrees; or having a 2.5 meter copper rod buried
at the local frost level or at least 1 meter below grade,
whichever is deeper (a connection to the water pipe system
does not constitute an adequate grounding electrode)."
If No, please explain in detail.
|
|
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• All information provided on this site is for the sole
use of The Insurance Centre Inc., any unauthorized access
to or use of this information may be deemed as a criminal
offence which may result in prosecution. |
