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First Name *

Last Name *

Email Address *

Phone *

Address *

City *

Province *

Postal Code *

When should your new coverage start? Select date... *

How would you like to be contacted? Phone Email *

What is your occupation?

How did you hear about us?

Age of Building: Please select... Less than 1 year 1 to 20 years 20 to 35 years more than 35 years *

Construction of Building Please select... Masonry Non-combustible Fire-resistive *

Years Continuously Insured: *

Is building sprinkled? Yes No *

How much area do you occupy? Please select... 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? Please select... Retail Office Building ownership wholesale Operations Farm Service Operations Contractor Garage Operations Manufacturer Other *

How many years in the business? Please select... Less Than 1 year More than 5 years *

Have there been any insurance claims in the last 3 years? Yes No

How much revenue does your business earn in a year? Please select... 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? Please select... Up to $50,000 $51,000 to $100,000 $101,000 to $500,000 $501,000 to $1,000,000 Over $1,000,000 *