Company Name
Address:
City:
Province:
Postal Code:
Principle Contact Name
Contact Method 1
Business Phone Home Phone Mobile Phone Busines email Personal email
Contact Method 2
Contact Method 3
Nature of Office Business
Years in Business
Experience with same type of business
Gross Receipts last year
Estimated number of client in the office per day
Do you have Professional insurance (E&O)
Y N
Claims History (check here if none in previous 5 years )
Claim #
Date
Type
Total Amount
Have you ever been canceled, declined or refused insurance? Y N
Limits Required (Please put N/A where specific insurance is not needed)
$1 Million $2 Million $5 Million
* While this will be enough information to provide you with a quick quote we will need more information to offer a written quote and/or bind a policy
