Basic Information:
Name of Insured:
Name of Principals:
Street Address:
City: Province: Postal Code:
Years in Business:
Contact Name:
Phone #: Email:
Previous Insurer:
Policy No: Expiry Date:

Have you ever had your insurance declined:        If yes, please provide details below:

How many loses have you had in the last five years, (if applicable)?
Date: Amount Outstanding: Amount Paid: Description:


Are you aware of an occurence that may lead to a claim?        If yes, please provide details below:
   
Location 1 Details:
Address: (if different from Postal Address)
Street Address:
City: Province: Postal Code:

Mortgage(s)/Loss Payee(s):
Company: Address: Postal Code:



Please describe what is located on each side of the building you occupy:
Front:
Behind:
Left:
Right:

Construction Details:
Roof:    Please Describe:
Walls:    Please Describe:
Floor:     
Heat:     
Air Conditioning:     
Building Type:     
Sprinklers:     
Year Built:     


What year was the following upgraded?
Roof: Heat: Plumbing: Electrical:



Total square meters of building:
Total square meters you occupy:
Total number of storeys:
Total no. of stories you occupy:
Number of Units/Suites:
Burglar Alarm:
Do you have a Parking Lot:

Number of Spaces:
Hydrant Protection:
Distance to Fire Hall:

Who are other tenants?

Details for physical protection for all windows, doors and other openings:
Safe: Please describe:
Max. amount of cash on premises during working hrs:
Max. amount of cash on premises overnight:
   
Location 1 Limits:

Coverage Items Deductible Limit
Building $
Stock $
Equipment $


Standard Limits - Higher Limits Available:

Coverage Items Deductible Limit
Accounts Receivable $ 50,000
Transit $ 25,000
Fine Arts $ 25,000
Valuable Papers $ 50,000
Sewer Backup $ 50,000
Professional Fees $ 50,000
Loss of money Inside /
Outside the Premises		 $ 10,000
CGL $ 1,000,000


Optional Coverage:

Coverage Items Deductible Limit
Umbrella $

Earthquake

 $100,000 $
Flood $25,000 $
Group Accident $
   
Operation Details:

Do you have any boilers or pressure vessels that require certification?        Please describe below:
Gross Annual Sales:
Annual rents Receivable: Annual Payroll:
No. of full-time clerical employees: No. of other full-time employees:
No. employees handling money:
Any repairs or installations off premises?
Do you use subcontractors?
Do you own or operate any subsidiary companies?

Additional Comments: