Safety Instructor Motorized Vehicles Application

Business Information

1. Applicant's Legal Name:
2. Operating as:

   Not-applicable
3. Mailing Address of Business:

   (Address)

   (City)

   AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon (Province)

   (Postal Code)

   (Email Address)

   (Email Address #2)

   (Phone)

   (Website)
4. Please provide a full description of the business operations coverage is desired for:
5. Revenues: Total operations gross revenues for all activities annually:

   $
6. Years in Operation:
7. Years of Experience:
8. Effective Date Desired:
9. What is the name of your Prior Insurance Carrier:
   Expiry Date:

   Certified Safety Training Instructor Information (complete for each instructor)

10. Name of certified Instructor:

    (Last Name, First Name, Middle name)
11. Date of Birth (Day/Month/Year):
12. Mailing Address of Certified Safety Training Instructor:

    (Address)
    (City)

    AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon (Province)

    (Postal Code)
    (Phone)

    (Email Address)
    (Fax)

    (Website)
13. The Canadian AQCC Safety Institute (CASI) 192 Niagara Street, London, Ontario N5W1R6 provides certification for Quad Instructors. If this is where you have certification from please provide your Council Instructor Certification Number:
    If you are not CASI certified, please indicate by which organization you became certified including a mailing address, web site and contact or email address. Ex. Canada Safety Council, contact information, as well as provide the Certification Number:
    Are you a member of any of the following: The All-Terrain Quad Council of Canada:

    YesNo

    The Motorcyclists Confederation of Canada:

    YesNo

    Other motorized off-road organizations:

    YesNo
    Name of other organization (if applicable):
14. How long have you been instructing the Safety Training courses?
15. Name of additional certified instructors you employ if applicable:
16. Are you a member of any Associations or Groups:

    General Operations

17. Specify which safety training course(s) you provide:
    Do you also do any Safety Training / Instruction in other areas: The All Terrain Vehicle Course:

    YesNo

    The Off-Road Motorcycle Course:

    YesNo

    The Snowmobile Safety Course:

    YesNo

    Other:

    YesNo

    Other:

    YesNo
18. Do you have First Aid Training?  

    YesNo
19. What is the duration of the Safety Training course?
20. What is the normal operating season, in which you offer the Safety Training course?
21. Do you provide transportation to and from the Safety Training Site for the participants?

    YesNo
    If yes, please explain:
22. Do you supply the participants with any equipment?

    YesNo
    If yes, please describe items:
23. Do you rent equipment to the participants?

    YesNo
    If so, what items?
24. Are participants required to wear an approved Motorized Vehicle Helmet (DOT, Snell, etc.) at all times when on the safety training site?

    YesNo
25. Are you responsible for the set-up and/or maintenance of the Safety Training Site?

    YesNo
    If not, please provide the name, address and telephone number of the person(s) responsible.
26. What is the minimum age of a participant to take part in the Safety Training course?
27. If operators are under the age of majority, are all minor participants accompanied by a parent or adult guardian?

    YesNo
28. How many Safety Training courses do you deliver in total, per calendar year?
29. What is the maximum number of participants per course?
30. List the Instructor/participant ratio:
31. Do you carry communication devices while instructing the Safety Training course?

    YesNo
    If so, what devices do you carry?
32. Where do you conduct the Safety Training course? Please provide a name, civic address or description of location, and telephone number of the owner of the property.
33. Do you own or rent the Safety Training site:

    OwnRent
    If owned please provide further details on the layout / photos
34. Are there any lakes or rivers on the Safety Training Site property?

    YesNo
35. Are all Safety Training Site specifications within the Canada Safety Council guidelines?

    YesNo
36. Do you require proof of provincial registration (license) and third party liability insurance on each unit to be used during the Safety Training course, before training begins?

    YesNo
37. Do you require all participants to sign a liability waiver form(s) (Canada Safety Council) before Safety training begins?

    YesNo
38. Does the waiver utilized properly acknowledge minors when applicable?

    YesNo
39. Do you have non certified assistants help you teach the course?

    YesNo
    If so, how many?
    If so, do they restrict their duties to a non-professional capacity?

    YesNo
40. Do you operate your own vehicle during safety training courses?

    YesNo
    If yes, how many units?
41. Do you authorize third parties vehicles or other potentially obstructive objects to be in the training area during safety training courses?

    YesNo

    Detail all claims or incidents that could have resulted in claims.

42. If you require additional space to record, please include a separate sheet of paper. Be certain to include your name, address and certification number on this sheet of paper. Describe any claims, incidents or near misses in the last five (5) years:
43. Are there any pending incidents or near misses that could produce an insurance claim?

    YesNo
    If yes, please provide details:
44. Have you had any insurance declined or cancelled?

    YesNo
    If yes, please explain:
45. Loss History for the last five years: