Business Insurance Applicaton

Please fill out the following information below

Contact Informaton --------------------------------------------------------------------------------

Name:

Address:

City:

Province:

Postal Code:

Email Address:

Home Phone:                   (                    )

Cell Phone:                       (                    )

Fax Phone:                        (                    )

Preferred method of contact:

Insurance Informaton --------------------------------------------------------------------------------

Location same as billing address?:

Location if no:

Operations:

Additional Description:

Approx. annual revenue:

Building Information:

Heating system:(Age of furnace)

Wiring:(Age of Panel box, etc.)

Plumbing:(When were last updates done?)

Do you have a home based business?:

Year Building Built:

Square footage:

If you are in a rural location, how far is the
nearest firehall?:

Do you have a basement?:

Other distinguishing features:

Do you have any other property or special
items that require insurance coverage?: