Basic Company Details
Are You an Existing Tripemco Client?
Company Name
Primary Address
Contact Name
Position
Email Address
Telephone Number
Website
Type of Organization?
For Profit, Privately Held
For Profit, Publicly Traded
Not-For-Profit
Is the Organization Incorporated
If Yes, Date of Incorporation?
Description of Business Activities
Description of Activities Outside of Canada
Last 12 Months Gross Revenue (Canadian)
Last 12 Months Gross Revenue (US)
Last 12 Months Gross Revenue (Foreign)
Total Canadian Assets ($)
Total US Assets ($)
Total Foreign Assets ($)
Number of Directors/Officers
Number of Shareholders
Number of Shareholders Holding More Than 25% of Total Shares
Employment Practices Liability
Total Number of Employees
Number of Unionized Employees
Number of Non-Unionized Employees
Number of Full-Time Employees
Number of Part-Time Employees
Number of Employees With Annual Compensation Greater Than $100,000
Number of Voluntary Terminations
Number of Involuntary Terminations
Number of Layoffs
Does the Organization Have:
Written Hiring and Interviewing Guidelines
Written Employment Agreements With All Officers and Managers
An Employee Handbook, Distributed to All Employees
Written Job Descriptions for All Positions
A Written Policy Against Discrimination and Sexual Harassment
A Written Policy Dealing With the Use of Company E-Mail, Voicemail and Internet Access
A Human Resources Department
Does the Organization Use Outside Legal Counsel for Employment Advice
Is Legal Counsel Consulted Prior to Discharging an Employee
During the Last 3 Years Have Any of the Directors, Officers, Employees, or the Organization Been Involved in Any:
Insolvency and/or Bankruptcy Proceedings
Are There Any Pending Claims or Knowledge of Any Claims or Incidents Against Any Person or the Organization That Is Applying for Coverage?
Fiduciary Information
Do you require Fiduciary Liability coverage?
Prior Insurance and Claims History
Have you purchased this type of insurance before?
If 'Yes', Provide Insurer, Expiry Date, and Limit
Have There Been Any Claims Made Against Any Person or Organization Applying for This Coverage in the Last 3 Years?
If ‘Yes’, Please Provide More Information Below:
Important Notice
By signing this form you agree that the information provided is both accurate and complete and that you have made all reasonable attempts to ensure this is the case by asking the appropriate people within your business. Tripemco Insurance Group will use this information solely for the purposes of providing insurance services and may share your data with third parties in order to do this. We may also use anonymized elements of your data for the analysis of industry trends and to provide benchmarking data. For full details on our privacy policy please visit
tripemco.com/privacy-policy
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