Main Contact's Full Name: Phone Number: Email: Website:
Policy Period Effective Date: Policy Period Expiry Date:
Applicant Data: Individual Joint Venture Corporation Other If Other:
Distance to the nearest hydrant: Ft. Metres
Distance to the nearest fire hall: Ft. Metres
Ground Floor Sq. M Sq. Ft.
Applicant’s Premises Sq. M Sq. Ft.
Building Total Sq. M Sq. Ft.
Renovation UpdatesElectrical Year completed Full Partial Plumbing Year completed Full Partial Heating Year completed Full Partial Roof Year completed Full Partial
Other Physical Protection: Dead Bolt Locks Window Bars Cameras Security Guards Exterior Lighting Safe If they have a safe please specify type and class:
Building Equipment Amount$ Stock - Amount$ Office Contents - Amount $ Contractor's Equipment - Amount $ Electronic Data Processing Systems Media Breakdown Mobile Truck Floater Max. Value of any one item$ Business Interruption Rental Income - Amount$ Extra Expense Earthquake Flood Sewer Backup Equipment Breakdown Money & Securities Money Orders & Counterfeit Currency Depositors Forgery Employee Dishonesty Burglary Damage Building Safe Burglary Liability - Amount $ Standard Non-Owned Automobile Blanket Contractual Products & Completed Operations OperationsDamage to Hired Automobiles Contractual Liability Non-Owned Auto
Number of EmployeesFull-Time: Part-Time:
Estimated Gross Annual Revenue $ CAD USD
Off Premises Operations Yes No Receipts $Description
Work Sub-Contracted Yes No Receipts $Description
Percentage of Construction Work which is:Residential % Commercial % Heavy Industrial % Other %
Are Sub-Contractors Insured: Yes No Amount of Insurance $
Any Special Hazards? Welding/Cutting Tobacco Flammable Liquids Spray Painting Woodworking Cooking
Liquor Sales: Yes No Total Receipts $
Additional insured(s)Name: Address: Street Address Address Line 2 City Province Postal Code Nature of Interest:
Property seen? Yes No When? Date Condition: Good Fair Poor