Hickey & Hyndman Insurance Ltd.

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Name:
Address:
City:
Province:
Postal Code:	(X1Y 2Z3)
Phone Number:	(123-456-7890)
Fax Number:	(123-456-7890)
Email Address:	(xxx@yyyy.zzz)
Age of building:
Construction of building:
Is the building sprinklered?	Yes No
How much area do you occupy?
Are you the only tenant?	Yes No
Is there a hydrant within 500 ft. (150 metres)?	Yes No
Is there a fire hall within 3 miles (5 kms)?	Yes No
Has insurance ever been denied or canceled?	Yes No
What type of business?
How many years in the business?
Have there been any insurance claims in the last 3 years?
What are the annual receipts?
What is the annual payroll?
Current Insurer:
Current Coverage	Building Limit Amount $ Equipment/Stock Limit Amount $ Commercial General Liability Limit Amount $
Current Policy Expiry Date: