Quote Request

Business Insurance
*Mandatory field
Full legal name of insured:*
Contact name:*
Contact Title:*
Email Address:*
Total number of locations
(including address below):
Main Location Address:*
City:*
Province:*
Postal Code:*
Phone Number:*
Fax Number:
Reason for call:
Is the business currently insured?
Yes     No
If yes, give Name of Insurer, Policy #, Expiry date & expiring Premium:
What type of business?
Please describe your operations in some level of detail:
What is the annual revenue?
How many years in business?
What is the annual payroll?
Do you sell products or services into the USA?
Yes     No
What coverages do you feel you require?
Have you been speaking to other brokers about arranging this insurance?
Yes     No
Have there been any insurance
claims in the last 3 years?
Yes     No
If yes, list all claims reported in the last 5 years showing:
i) Date of loss
ii) Amount paid
iii) reserve amounts.
(Include all claims that were closed without any payment)
Age of main location building:
Construction of main building:
Is the building sprinklered?
Yes     No
If building owned, what is total area? (sq. ft.)
How many stories in building you own?
If a tenant, how much area do you occupy? (sq. ft.)
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
Additional Comments:
   
 

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