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Business Insurance
Name of Business:
Contact Name:
Website:
Email Address:
Address:
City:
Province:
Postal Code:
Phone Number:
Age of building:
< 1 year
1 - 20 years
20 - 35 years
> 35 years
Construction of building:
Frame
Masonry
Non-Combustible
Fire Resistive
Is the building sprinklered?
Yes
No
How much area do you occupy?
< 5 000
5 000 - 10 000
> 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
Expiry/Renewal Date:
Existing/Prior Insurance Company Name:
Existing/Prior Insurance Policy Number:
What type of business?
Retail
Office
Building ownership
Wholesale operation
Farm
Service Operation
Contractor
Garage operation
Manufacturer
Other
How many years in the business?
< 1 years
1 - 5 years
> 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
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