Industry / Profession

Operating Name

Corporate/Business Name

Business Address

List of all owner(s)

First and last name, Title (if applicable)

Website

http://

Contact Person Name, Email, Phone Number

Last Year's Revenue

Last Year's Expense

How many years has the business been operating?

How many employees do you have?

both full time and part-time

Additional informaiton

please include any additional information regarding what you need to insure and the amount insurance needed

If answered yes above, please explain

If answered "other" above, please explain

Any special coverage is required?

If you have any special coverage requirements, please list them here

What is the total square footage of the unit?

Does the business have neighbors?

Please provide description of neighbor on left and right side of the business

If answered yes to above, which group carrier insurance is it?

If applicable, what is the name of your fire/burglar alarm company?

Please list any updates (Roof, Plumbing, Heating & Electrical) to the building and what year they were completed?

If applicable, please list your previous Commerical insurance carrier, your policy number and expiry date

Additional information

Please include any additional information relevant to the application

commercial Insurance form