Not Sure Which Location is Closest to You?Take a look at our locations map to find the office that is right for you!Find a Location! Step 1 of 7 14% GENERAL INFORMATIONBusiness Name* Contact Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address* Street Address Address Line• The type of policy issued by a company, e.g., fire line, automobile line, casualty line. • A given set of exposures making up an account. An... More 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Daytime Phone*Effective Date* MM slash DD slash YYYY Current InsurerThe company providing the insurance coverage. More* MULTIPLE LOCATIONS Please submit a new form for each property or business owned.This is Location:*12345of:*12345Business Address* Street Address Address Line• The type of policy issued by a company, e.g., fire line, automobile line, casualty line. • A given set of exposures making up an account. An... More 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Business Type*Please Select OneAutomotive ServicesBusiness and ProfessionalContractor and TradeHospitalityRealtyRetailWholesaleOtherIf other, please specify:* Form of Business Individually Owned Corporate Type of Products and/or Services Sold:*Manufactures Own Products:* Yes No Target Premium PolicyLegally binding contract effecting insurance or certificates thereof, including all clauses, riders, endorsements and renewals. More Deductible*Please Select One$500$1,000$2,500 BUILDING Please complete the following even if leasing.Value (if owned)Is all or a portion of this building rented to others* Yes No If 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* Yes No Square Footage of Building*Square Footage you Occupy*Square Footage Occupied by Others* ADJACENT OCCUPANCIES Please 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* None 1-8km 8-25km More than 25km Distance to Closest Fire Hydrant* None 1-8km 8-25km More than 25km Alarm System* Monitored Local None Alarm Alerts for:*Select all that apply. Intrusion Smoke Fire CO2 Number of Fire Extinguishers:*Please select one123455+Serviced Annually* Yes No If deep fat frying is done on premisesBuilding including the land immediately surrounding it and belonging to it. More, is an overhead fire suppression in place: Yes No If yes, indicate type: CO2 Chemical Is there a service contract in place:* Yes No When were the filters last cleaned?MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the Building Older than 20 years?* Yes No Plumbing* Month Day Year Primary Heating* Month Day Year Roof* Month Day Year Wiring* Month Day Year Indicate type of service for the following:Plumbing* Copper/ABS Galvanized Steel Primary Heating* Forced Air Gas Radiant (Stream) Electric Oil Propane Roof* Wood Steel Concrete Wood Joist (Peaked) Wiring* 100 amp 200 amp Supplementary Heating* Yes No If Yes, Type of Supplementary Heating:* Solid Fuel Stove Space Heaters Electric Transformer on PremisesBuilding including the land immediately surrounding it and belonging to it. More:* Yes No Air Compresser on PremisesBuilding including the land immediately surrounding it and belonging to it. More:* Yes No If any of the following are attached to the building please state value:SignClockAntennas/TowersGlass Coverage Required? Yes No Linear Footage of Glass: CONTENTSProduction EquipmentMaterial for use on one machine, one vehicle, one unit. For example, a car comes “equipped” with five tires. Tires other than those on the car are... More (value)*Total Stock (value)*Perishable Stock (value)*Work in Progress (value)*Tools on PremisesBuilding including the land immediately surrounding it and belonging to it. More (value)*Leasehold Improvements (value)*Office EquipmentMaterial for use on one machine, one vehicle, one unit. For example, a car comes “equipped” with five tires. Tires other than those on the car are... More (value)*Computer and EDP EquipmentMaterial for use on one machine, one vehicle, one unit. For example, a car comes “equipped” with five tires. Tires other than those on the car are... More (value)*Computer Software (value)*Property of Others (value)* CRIMEIs cash kept on premisesBuilding including the land immediately surrounding it and belonging to it. More: Yes No Amount (value)*Overnight (value)*Daily Deposit Amount*Safe on PremisesBuilding including the land immediately surrounding it and belonging to it. More: Yes No Class and Fire Rating* Employee Dishonesty Coverage*Please Select OneNone$2,500$5,000$10,000Employee Bonding Required*Please Select OneNone$2,500$5,000$10,000 ADDITIONAL COVERAGESWater Escape/Sewer Backup:* Yes No Flood:* Yes No Earthquake:* Yes No Exterior Sign(s) (value)*Transit (value)*Temp Locations (value)*Temp Floater (value):* Less than $1000 More than $1000 Actual Value*EquipmentMaterial for use on one machine, one vehicle, one unit. For example, a car comes “equipped” with five tires. Tires other than those on the car are... More Floater (value):* Less than $1000 More than $1000 Actual Value*Misc. EquipmentMaterial for use on one machine, one vehicle, one unit. For example, a car comes “equipped” with five tires. Tires other than those on the car are... MoreOther: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:* Yes No Cranes or Hoists on PremisesBuilding including the land immediately surrounding it and belonging to it. More:* Yes No If yes, value of highest amount hoisted (value):*Are you interested in a quote for a Liability Umbrella?* Yes No If yes, amount:*1,000,0002,000,0003,000,0005,000,00010,000,000How many vehicles do you own:* 1 2 3 4 5 5+ INSURANCE HISTORYCurrent or Most Recent InsurerThe company providing the insurance coverage. More* PolicyLegally binding contract effecting insurance or certificates thereof, including all clauses, riders, endorsements and renewals. More RenewalA certificate which attests to the fact that an insurance policy has been extended for another term. More Date or Last Date InsuredThe entity (individual or otherwise) whose risk of financial loss from an insured peril is protected by the insurance policy. More* Month Day Year Number of Years Consecutively InsuredThe entity (individual or otherwise) whose risk of financial loss from an insured peril is protected by the insurance policy. More:*None12345678910 List all claims in the past 5 years:Claim #1 Month Day Year Claim #1 Type Claim #1 Amount PaidClaim #2 Month Day Year Claim #2 Type Claim #2 Amount PaidClaim #3 Month Day Year Claim #3 Type Claim #3 Amount PaidMore than 3 claims? Yes No Please list any additional information in the box below:Which Office Would You Like to Submit this Quote to?*Select your officeAgincourtAjaxAncasterBarrieBramptonBurlingtonClairvilleDanforthEssexEtobicokeGeorgetownGrimsbyHamiltonBurlington NorthCathedral TownKingstonLeamingtonMarkhamMiltonNewmarketNiagara FallsOakvillePelmo ParkPickeringRenfrewRichmond HillSault Ste. MarieStoney CreekStreetsvilleSudburyTecumsehVictoria ParkWaterlooWhitbyWindsorNobletonNobletonBoltonButtonvilleCallanderErin MillsHighland CreekIslingtonKitchenerLondon EastMaritimeMeadowvaleNepeanNobletonNorth YorkOrleansPearsonNobletonUnionvilleVaughanWoodbridgeLondon SouthRouge ValleyPhoneThis field is for validation purposes and should be left unchanged.
