| * Name: |
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| * Email Address: |
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| * Address: |
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| * City: |
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| * Province: |
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| * Postal Code: |
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| * Phone Number: |
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| Fax Number: |
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| * Age of building: |
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| * Construction of building: |
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| * Is the building sprinklered? |
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| * How much area do you occupy? |
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| * Are you the only tenant? |
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| * Is there a hydrant within 500 ft. (150 metres)? |
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| * Is there a fire hall within 3 miles (5 kms)? |
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| * Has insurance ever been denied or canceled? |
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| * What type of business? |
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| * How many years in the business? |
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* Have there been any insurance
claims in the last 3 years? |
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| * What are the annual receipts? |
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| * What is the annual payroll? |
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| Additional Comments: |
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Toll Free: 1-866-284-4748
