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: YesNo How much area do you occupy: < 5,000 5,000 - 10,000 > 10,000 Are you the only tenant: YesNo Is there a hydrant within 500 ft. (150 metres): YesNo Is there a fire hall within 3 miles (5 kms): YesNo Has insurance ever been denied or canceled: YesNo 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 claims in the last 3 years: 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