Name:
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?
< 5000
5000 - 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
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
Has any company ever cancelled or
refused insurance of this description?
Yes
No
Additional comments:
Disclaimer
