Name:

Email Address:

Address:

City:

Province:

Postal Code:

Phone Number:

Age of building: < 1 year 1 - 20 years 20 - 35 years > 35 years

Construction of building: Frame Masonry Non-Combustible Fire Resistive

Is the building sprinklered?Yes No

Area Occupied (sq. ft.): < 5 000 5,000 - 10,000 > 10,000

Are you the only tenant?Yes No

Is there a hydrant within 500 ft. (150 metres)?Yes No

Is there a fire hall within 3 miles (5 kms)?Yes No

Has insurance ever been denied or canceled?Yes No

What type of business: Retail Office Building ownership Wholesale operation Farm Service Operation Contractor Garage operation Manufacturer Other

How many years in the business: < 1 years 1 - 5 years > 5 years

Insurance claims in the last 3 years: None <= 2 >= 3

What are the annual receipts: Up to $50,000 $51,000 to $100,000 $101,000 to $500,000 $501,000 to $1,000,000 Over $1,000,000

What is the annual payroll: Up to $50,000 $51,000 to $100,000 $101,000 to $500,000 $501,000 to $1,000,000 Over $1,000,000