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 Business
Years in Business
Experience with same type of business
Gross Receipts last year
Expected Gross Receipts this year
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
If Yes please put details below
Limits Required Please enter in the box below the coverage’s and limits you are looking for. i.e. tools, building, contents, commercial liability.
* 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
