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Name:
Email Address:
Address:
City:
Province:
Postal Code:
Phone Number:
Age of building:
Construction of building:
Is the building sprinklered?
Yes     No
How much area do you occupy?
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?
How many years in the business?
Have there been any insurance
claims in the last 3 years?
What are the annual receipts?
What is the annual payroll?
 

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