Step 1 of 714%GENERAL INFORMATIONBusiness Name*Contact Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Daytime Phone*Effective Date* Date Format: MM slash DD slash YYYY Current Insurer*MULTIPLE LOCATIONSPlease submit a new form for each property or business owned.This is Location:*12345of:*12345Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Business Type*Please Select OneAutomotive ServicesBusiness and ProfessionalContractor and TradeHospitalityRealtyRetailWholesaleOtherIf other, please specify:*Form of BusinessIndividually OwnedCorporateType of Products and/or Services Sold:*Manufactures Own Products:*YesNoTarget PremiumPolicy Deductible*Please Select One$500$1,000$2,500BUILDINGPlease complete the following even if leasing.Value (if owned)Is all or a portion of this building rented to others*YesNoIf yes, amount of annual rent collected:Year Built*Construction:Walls*Please select oneFrameBrick VeneerMasonryConcrete BlockSteel CladdingFloor*Please select oneWoodConcreteConcrete SlabAsphaltTar/GravelOtherRoof*Please select oneWoodSteelConcreteWood Joist (Peaked)Number of Floors*Basement*YesNoSquare Footage of Building*Square Footage you Occupy*Square Footage Occupied by Others*ADJACENT OCCUPANCIESPlease state business types/residencies surrounding your location. (i.e. Left Side - Law Firm, Right Side - Variety Store, Front - House, Behind - Alley)Left Side:*Front:*Right Side:*Behind:*Distance to Closest Fire Station*None1-8km8-25kmMore than 25kmDistance to Closest Fire Hydrant*None1-8km8-25kmMore than 25kmAlarm System*MonitoredLocalNoneAlarm Alerts for:*Select all that apply. Intrusion Smoke Fire CO2Number of Fire Extinguishers:*Please select one123455+Serviced Annually*YesNoIf deep fat frying is done on premises, is an overhead fire suppression in place:YesNoIf yes, indicate type:CO2ChemicalIs there a service contract in place:*YesNoWhen were the filters last cleaned?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the Building Older than 20 years?*YesNoPlumbing* MM DD YYYYPrimary Heating* MM DD YYYYRoof* MM DD YYYYWiring* MM DD YYYYIndicate type of service for the following:Plumbing*Copper/ABSGalvanized SteelPrimary Heating*Forced Air GasRadiant (Stream)ElectricOilPropaneRoof*WoodSteelConcreteWood Joist (Peaked)Wiring*100 amp200 ampSupplementary Heating*YesNoIf Yes, Type of Supplementary Heating:*Solid Fuel StoveSpace HeatersElectricTransformer on Premises:*YesNoAir Compresser on Premises:*YesNoIf any of the following are attached to the building please state value:SignClockAntennas/TowersGlass Coverage Required?YesNoLinear Footage of Glass:CONTENTSProduction Equipment (value)*Total Stock (value)*Perishable Stock (value)*Work in Progress (value)*Tools on Premises (value)*Leasehold Improvements (value)*Office Equipment (value)*Computer and EDP Equipment (value)*Computer Software (value)*Property of Others (value)*CRIMEIs cash kept on premises:YesNoAmount (value)*Overnight (value)*Daily Deposit Amount*Safe on Premises:YesNoClass and Fire Rating*Employee Dishonesty Coverage*Please Select OneNone$2,500$5,000$10,000Employee Bonding Required*Please Select OneNone$2,500$5,000$10,000ADDITIONAL COVERAGESWater Escape/Sewer Backup:*YesNoFlood:*YesNoEarthquake:*YesNoExterior Sign(s) (value)*Transit (value)*Temp Locations (value)*Temp Floater (value):*Less than $1000More than $1000Actual Value*Equipment Floater (value):*Less than $1000More than $1000Actual Value*Misc. EquipmentOther:Please describe and indicate value.OPERATIONS/LIABILITYAmount of Liability*Please Select One1,000,0002,000,0003,000,0005,000,000Total Annual Sales (value)*Liquor Sales (value)*Sales to U.S. (value)*Cost of Sales (value)*Key Person Payroll (value)*Ordinary Payroll (value)*Number of Employees*Years in Business*Years in this Industry*Do your employees use their own vehicles on behalf of your business:*YesNoCranes or Hoists on Premises:*YesNoIf yes, value of highest amount hoisted (value):*Are you interested in a quote for a Liability Umbrella?*YesNoIf yes, amount:*1,000,0002,000,0003,000,0005,000,00010,000,000How many vehicles do you own:*123455+INSURANCE HISTORYCurrent or Most Recent Insurer*Policy Renewal Date or Last Date Insured* MM DD YYYYNumber of Years Consecutively Insured:*None12345678910List all claims in the past 5 years:Claim #1 MM DD YYYYClaim #1 TypeClaim #1 Amount PaidClaim #2 MM DD YYYYClaim #2 TypeClaim #2 Amount PaidClaim #3 MM DD YYYYClaim #3 TypeClaim #3 Amount PaidMore than 3 claims?YesNoPlease list any additional information in the box below:Which Office Would You Like to Submit this Quote to?*Select your officeAgincourtAjaxAncasterBarrieBloorBramptonBurlingtonChathamClairvilleCliffsideDanforthEssexEtobicokeGeorgetownGreater NapaneeGrimsbyHamiltonCampbellvilleCathedral TownKingstonLeamingtonLondon NorthMarkhamMiltonMississaugaNewmarketNiagara FallsOakvilleOttawaPelmo ParkPickeringRenfrewRichmond HillSault Ste. MarieStoney CreekStreetsvilleSudburyTecumsehVictoria ParkWaterdownWaterlooWillowdaleWindsorBowmanvilleHornbyLondon SouthEmailThis field is for validation purposes and should be left unchanged.
