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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:
Less than 1 year
1 to 20 years
20 to 35 years
More than 35 years
Construction of building:
Frame
Masonry
Non-Combustible
Fire Resistive
Is the building sprinklered?
Yes
No
How much area do you occupy?
Less than 5,000
5,000 to 10,000
More than 10,000
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?
Retail
Office
Building ownership
Wholesale operation
Farm
Service Operation
Contractor
Garage operation
Manufacturer
Other
How many years in the business?
Less than 1 years
1 to 5 years
More than 5 years
Have there been any insurance
claims in the last 3 years?
No
<= 2
>= 3
What are the annual receipts?
Up to $50,000
$51,000 to $100,000
$101,000 to $500,000
$501,000 to $1,000,000
Over $1,000,000
What is the annual payroll?
Up to $50,000
$51,000 to $100,000
$101,000 to $500,000
$501,000 to $1,000,000
Over $1,000,000
Current Insurer:
Current Coverage
Building Limit
Amount $
Equipment/Stock Limit
Amount $
Commercial General Liability Limit
Amount $
Current Policy Expiry Date:
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