Commercial Insurance

*(denotes required field)

First Name: *

Last Name: *

E-Mail Address: *

Address:

City:

Province:

Postal Code:
(X1Y 2Z3)

Phone Number:
(123-456-7890)

Age of building:

Construction of building:

Is the building sprinklered?

Yes No

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How much area do you occupy?

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?

How many years in the business?

Have there been any insurance claims in the last 3 years?

What are the annual receipts?

What is the annual payroll?

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