Business Insurance
	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       Disclaimer