Policy Period Effective Date: Policy Period Expiry Date:
Applicant Data:Individual Joint Venture Corporation Other If Other:
Would you also be interested in a quote for:Commercial Auto Errors & Omissions Directors & Officers Group Health Other If Other:
Electrical Year completed: Full Partial
PlumbingYear completed: Full Partial
HeatingYear completed: Full Partial
RoofYear completed: Full Partial
Building Equipment: Amount Stock: Amount Office Contents: Amount Contractor's Equipment: Amount Electronical Data Processing Systems Media Breakdown Mobile Truck Floater | Max. value of any one item $ Business Interruption Rental Income: Amount $ Extra Expenses 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 Operations Damage to Hired Automobiles Contractual Liability Non-owned Automobile
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 $
Liquor Sales Yes No Total Receipts: $
Additional Insured(s)First Name Last Name Street Address Address Line 2 City Province Postal Code Nature of Interest: