Contact Information
Business Name:
Contact Person
Address:
City:
Province:
Postal Code:	(X1Y 2Z3)
Phone Number:	(123-456-7890)
Fax Number:	(123-456-7890)
Email Address:	(xxx@yyyy.zzz)
GTA Amateur Tour Member?	Yes    No
Age of building:	Less than 1 year 1 to 20 years 20 to 35 years More than 35 years
Construction of building:	Frame Masonry Non-Combustible Fire Resistive
Is the building sprinklered?	Yes    No
How much area do you occupy?	Less than 5,000 5,000 to 10,000 More than 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?	Less than 1 years 1 to 5 years More than 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
Do you currently have business insurance?	Yes    No
Expiry Date of Coverage:
Coverage Details Property
Building Stock Equipment Office Contents Contractors Equipment Floater Tool Floater Tenants Improvements Property In Transit Exterior Glass Exterior Sign Other Property Deductible Select 500 1000 1500 2000 2500 Replacement Cost Yes    No Flood Yes    No Earthquake Yes    No Sewer Backup Yes    No Crime   3D Bond In/out Robbery Indirect Damage   Business Interruption Profits Form Extra Expense Gross Rental Values Consequential Loss Liability   Commercial General Liability  Limit 1,000,000 2,000,000 5,000,000 Non-owned Automobile Liability  Limit 1,000,000 2,000,000 5,000,000 Tenants Legal Liability Boiler and Machinery   Form-Comprehensive Production Machines Electronic Machines
Comments: