Full Name of Applicant
*
First Name
Last Name
Company Name
Address (including Postal Code)
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
*
(###)
###
####
Full Details of Operations & Experience
Name of Current Insurance Company
Policy number of current insurance policy
Expiry date of current insurance policy
Any claims in the last 5 years?
Wall Construction
Roof Construction
Floor Construction
Number of stories:
Type of heating:
Year built:
If the building is over 35 years old, have updates been carried out?
Yes
No
Sprinklered?
Yes
No
Premises occupied by others?
If yes, please provide full details:
Fire Alarm
Burglar Alarm
Extent of protection
Details of physical protection, locks on doors, bars or windows etc. (see Loss Control Checklist):
Safe:
Yes
No
If yes, please describe:
Total number of employees:
Number of employees handling money:
Maximum amount of cash on premises:
Receipts $
Canadian Sales $
U.S. Sales
No
Yes
Are Subcontractors used?
No
Yes
If yes, please describe:
Use of Information
*
Clicking on I agree means that you agree that we may collect, use and disclose your information in order to comply with legal and regulatory requirements, and other purposes which are described in the Privacy Agreement. You also understand that in order to better meet your needs going forward, we may use the information to stay in touch with you (by phone, at the numbers you provided, by email, by mail or other methods) and keep you informed about our products and services.
To continue with the quote process, you need to agree to our privacy agreement.
