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?
How much area do you occupy?
< 5,000
5,000 - 10,000
> 10,000
Are you the only tenant?
Is there a hydrant within 500 ft. (150 metres)?
Is there a fire hall within 3 miles (5 kms)?
Has insurance ever been denied or canceled?
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
Have there been any insurance
No
<= 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
