Business Insurance Quote Request
Business Details:
Legal name
*
Operating name (if any)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main phone
*
Please enter a valid phone number.
Main email
*
example@example.com
Website
Legal entity:
*
Sole proprietorship
Partnership/Joint venture
Incorporation
Other
Contact Person Details:
Contact person's full name
*
First Name
Last Name
Contact person's phone no.
*
Please enter a valid phone number.
Contact person's email
*
example@example.com
Back
Next
Insurance Details:
Current insurance company name (if applicable)
Current insurance policy number (if applicable)
Effective/renewal date
*
-
Month
-
Day
Year
If renewal was not being offered, please explain.
Describe all claims, including any outstanding, and fees for the last five years including any accidents, facts, circumstances or allegations which may give rise to a claim:
What action has been taken to eliminate future accidents?
Has any similar insurance applied for or carried by the Applicant been declined or cancelled by any insurer within the last three years?
*
Yes
No
If “Yes”, please provide full details.
*
Back
Next
Business Risk Assessment:
Business start date
*
-
Month
-
Day
Year
Date
No. of years of related prior experience
*
Please provide the best estimated values for the following: If N/A, then enter 0
*
Revenue
Payroll
# of Employees
a) Canada
b) US
c) Others
If “Other”, please provide details:
Are company owners, executive officers or other office employees covered under Worker’s Compensation?
*
Yes
No
Please provide list of all operations performed and the breakdown for operation to the total revenue. Please fill up as many rows as needed.
*
Operation
%
1
2
3
4
5
6
7
8
9
10
Location of all of premises, operations, also indicate Owner; Lessee; Tenant. Please fill up as many rows as needed.
*
Operation performed
Location Address including Postal Code
O/L/T
1
Owner
Lessee
Tenant
2
Owner
Lessee
Tenant
3
Owner
Lessee
Tenant
4
Owner
Lessee
Tenant
5
Owner
Lessee
Tenant
6
Owner
Lessee
Tenant
7
Owner
Lessee
Tenant
8
Owner
Lessee
Tenant
9
Owner
Lessee
Tenant
10
Owner
Lessee
Tenant
Total property value (Please include all office furniture, computers, laptops, equipments, etc.)
*
Other details for insurance purposes (if any)
Back
Next
By submitting my information, I understand and acknowledge that - HIFA insurance may contact me via phone, text and/or email to update about their services and Help Me Project activities. HIFA insurance may also share my contact details with their partners and associates.
Submit
Should be Empty: