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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:
< 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
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
Overview
Automobile Insurance
Property Insurance
Combined Home and Auto
Business Insurance
Boat Insurance
Farm Insurance
Recreational Vehicle
Travel Trailer Insurance
Term Life Insurance
Critical Illness Insurance
Disability Insurance
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Key Person Insurance
Tenants Insurance
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