* – Required

First Name *: Last Name *:
Email *:
Address:
City: Province: Postal Code *
Phone *: Phone/Other:
Type of Business:
Years in Business:
Previous Insurance Company:
Expiry Date:
Building (General)
Number of Storeys
Number of Units
Year Constructed
   
Construction /
Condition of Building
Walls
Roof
Electric (fuses or circuit breakers)
Heating
Air conditioning
Sprinklers Entire building RoofUnderground Parking

Number of fire extinguishers
Alarms/Security Burglar
Fire
De-Vac Line/or monitored

Name of monitoring company:

Camera Surveillance
Windows Barred
Guard Dog
Other

Footage / Occupancy
Square footage occupied ft
Total square footage of building ft
Occupancy
Other Occupants
Amount of Insurance
Building $
Equipment $
Stock $
Liability $
Comments:

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