Client Information
Contact Person
First name Last name
Email
Phone
Business Information
Name of Applicant
Business Legal Name
Operating Name if different
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Business Operation
Describe the nature of business operation.
Webpage
BIN Number
9 digits
Years of Business Experience
Is the business currently insured?
Present Insurer
Policy Number
Existing Business Policy Attachment
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Have you ever had an insurance policy non-renewal, cancelled, or declined?
If yes, please describe details
Any claims in the last 5 years?
If yes, please describe details and paid out amount
Company Annual Gross Income/Sales:
Source of Business
Canada: _______%
USA: _______%
Asia: _______%
Europe: ______%
Number of Employees
# Full Time
# Part Time
Annual Payroll:
Are subcontractors being used? What are their duties and what percentage do you subcontractors annually?
Property coverages
Is the applicant the owner or tenant of the property?
Owner
Tenent
What year was the unit or building built?
Size and Square Feet of building ?
Gross usage Sq Feet
Construction type of building and roof?
Does it have a monitored burglar or fire alarm?
Does the building have a sprinkler system?
How much would it cost to replace all the property inside the unit/ building?
Equipment, furniture, inventory, appliances, supplies.
Is any space leased out?
Are tenants you lease to required to list you as additional insured on their insurance?
Following question related to
Commercial Auto Coverage
How many vehicles do you have?
Description of what vehicles are used for:
How is the vehicles used?
Annual milage, operation distance. Product delivery or carrying third party cargo?
Garage Location
Copy of Driver's list (include names, date of birth and driver license numbers), Copy of Vehicles List: Year, Make, Model and VIN#.
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Describe any auto claims in the last 5 years:
Select desired coverage's below
General Liability Coverage
Business Interruption
Employer Liability
Micellaneous
aDDITIONAL INFORMATION TO INCLUDE:
OPTIONAL:
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