Dental Commercial Quote

Operator’s Legal Name:      
Mailing Address:   Street Address   Address Line 2   City   Province   Postal Code   
   
Main Contact's Phone Number:   Area Code   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 Updates
Electrical 
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:
   

Number of Employees
Full-Time:      
Part-Time:      

Additional insured(s)
Name: Full Name   Address: Street Address   Address Line 2   City   Province  Postal Code   

Nature of Interest:
   

Additional insured(s)
Name: Full Name   Address: Street Address   Address Line 2   City   Province  Postal Code   

Nature of Interest:
   

Additional insured(s)
Name: Full Name   Address: Street Address   Address Line 2   City   Province  Postal Code   

Nature of Interest:
   

Additional insured(s)
Name: Full Name   Address: Street Address   Address Line 2   City   Province  Postal Code   

Nature of Interest:
   

Property seen? Yes   No   When?   Date   
Condition:   Good   Fair   Poor