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| Name: |
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| Address: |
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| City: |
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| Province: |
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| Postal Code: |
(X1Y 2Z3) |
| Phone Number: |
(123-456-7890) |
| Fax Number: |
(123-456-7890) |
| Email Address: |
(xxx@yyyy.zzz) |
| Age of building: |
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| Construction of building: |
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| Is the building sprinklered? |
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| How much area do you occupy? |
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| Are you the only tenant? |
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| Is there a hydrant within 500 ft. (150 metres)? |
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| Is there a fire hall within 3 miles (5 kms)? |
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| Has insurance ever been denied or canceled? |
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| What type of business? |
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| How many years in the business? |
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Have there been any insurance
claims in the last 3 years? |
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| What are the annual receipts? |
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| What is the annual payroll? |
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| How did you hear of us?: |
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