Step 1 of 7 14% 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Daytime Phone*Effective Date* MM slash DD slash YYYY Current Insurer* MULTIPLE LOCATIONS Please 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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 Policy 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 premises, 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?MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is 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 Premises:* Yes No Air Compresser on Premises:* 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 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: Yes No Amount (value)*Overnight (value)*Daily Deposit Amount*Safe on Premises: 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*Equipment Floater (value):* Less than $1000 More than $1000 Actual 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:* Yes No Cranes or Hoists on Premises:* 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 Insurer* Policy Renewal Date or Last Date Insured* Month Day Year Number of Years Consecutively Insured:*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:EmailThis field is for validation purposes and should be left unchanged.
