*Contact Name:
*Phone Number:
*Email Address:
Company Name:
Fax Number:
Address:
City:
Province:
Postal Code:
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 cancelled?	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
Number of Employees:
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

Disclosure and Privacy Statement