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 Retail Business
Years in Business
Experience with same type of business
Gross Receipts last year
Expected Gross Receipts this year
Canadian Sales
%
US Sales
Internet Sales
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
