Business Insurance Applicaton

Because of the different variables affecting your insurance premiums, we need a few pieces of information from you. To get started on your application, please fill out the following fields below. After you send it, we'll get back to you as timely as possible.

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

Last 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?:

First Name: