commercial submission

Depending on the nature of the risk you are trying to have quoted, some of these questions may or may not pertain to your risk, we ask that you answer as much as possible and we will follow up if something is missed or not fully understood, we understand that their are many questions on this page, but they are questions that most insurers will ask before they can insure you, we ask from the initial contact so that we can attain accurate information on your risk and provide you with an accurate quote. This will also save us both alot of time when we bind your application, its just an attempt for better customer service.

your info

have you had any previous insurance?

if yes, indicate the previous insurance company:

policy number:

expiry date:

your business

name of business:

business address (include include city, postal code):

mailing address (if different than business location):

contact person:

phone number:

fax number:

email address:

loss payee

loss payee(s) contact person:

loss payee(s) business address (include include city, postal code):

operation/occupancy

what type of operation are you?

by selecting other, this would apply to a rented dwelling. please indicate whether this is a 4-plex, 6-plex, 3-story walkup, etc.:

please select the type of operation you run:

number of employees:

payroll:

years of business experience:

name of prior company:

reason for closing:

years of operation:

business hours:
from: to: for # of days:

building details

age of building:

number of stories:

sq. foot of building:

sq. foot per floor:

sq. foot occupied by insured:

hydrant protected: yes no

is hydrant distance within 300m: yes no

is firehall protected: yes no

is distance within 8km: yes no

building structure type:

does the building have a sprinkler system: yes no

are there fire extinguishers: yes no

last inspection date done on extinguishers:

is there a fire alarm: yes no

is there a burglar alarm: yes no

if there is a burglar alarm, what type is it:

certificate number:

how are the windows protected: tape bars

how are the doors protected: bars deadbolt

is there a safe: yes no safe class:

is there a swimming pool: yes no

if yes, is it fenced and locked: yes no

please indicated the dimensions of the pool:

are there any exercise facilities: yes no

is there a playground area: yes no

is there laundry facilities: yes no

are they shared: yes no

who takes care of snow removal:

does owner live on premises: yes no

last inspection date of fire & hyrdo codes:

building claims

are tennants required to carry their own insurance: yes no

have there been any claims in the last 5 years: yes no

claim 1
date:type of claim:amount paid:

claim 2
date:type of claim:amount paid:

claim 3
date:type of claim:amount paid:

claim 4
date:type of claim:amount paid:

claim 5
date:type of claim:amount paid:

building walls

indicate the wall type in the building:

other types of walls:

building floors

indicate the floor type in the building:

other types of floors:

building roof

indicate the roof type in the building:

other types of roof:

when was the roof last updated or changed:

building basement

does the building have a basement: yes no

rented units information

if a rented dwelling, please indicate how many units are below grade:

is each unit a self-contained apt with own kitchen and bath: yes no

indicate how many 3 bedroom units:

indicate how many 2 bedroom units:

indicate how many 1 bedroom units:

indicate which type of wiring applies:

date of last wiring upgrade:

amp service:

if you selected other, please specify:

heating type

please indicate which type of heating applies:

if you've selected radiators, please indicate approximately how old they are:

plumbing type

please indicate which type of plumbing applies:

if you've selected radiators, please indicate when they were last upgraded:

other occupancies

are there any other types of occupancies (separate uses) of the buidling: yes no

if yes, please explain:

adjoining buildings

describe the adjoining buildings:
adjoining left:

adjoining right:

adjoining back:

adjoining front:

to whom it applies

is there a co2 system: yes no

if yes, is it wet or dry: wet dry

is there a 6 month maintenance agreement: yes no

what is the maintenance company's name:

are you liquor licensed?: yes no

coverages

please select the coverage type:

replacement cost: yes no

actual cash value: yes no

deductable:

other:

property of every description (poed)

building amount required:

contents:

machinery/equipment:

electronic data processing:

stock:

consequential loss assumption:

sign floater:

glass (blanket): yes no

linear footage (glass):

is the glass: thermo non-thermo

goods in transit:

contractors equip floater:

tool floater:

business interruption

gross earnings:

profits from:

extra expense:

annual amount:

crime coverages

broad form money and securities (subject to safe on premises): $

inside/outside: $

3d bond: $

fidelity bond: $

number of employees: $

multi-peril

accounts receivable: $

valuable papers: $

boiler and machinery

comprehensive form: yes no

broad form: yes no

property damage limit:

consequential loss assumption:

business interruption: yes no

profits:

gross earnings:

extra expenses:

rental income:

liability

deductable:

other:

commercial general liability:

non-owned automobile:

owners, landlords, tenants:

tenants legal liability:

other (medical payments):

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