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):

building details

indicate building type (4-plex, 6-plex, 3-story walkup, etc.):

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 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 tenants 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:

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:

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:

rental income:

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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