Please complete the form as accu

Business Application-Bonds-Buildings

Please complete the form as accurately as possible in order to ensure the best possible estimate. If you would rather speak to one of our brokers, please call us at (613) 549-8777 or 1-800-881-2371.

Completion of this form is for informational purposes only, and is just an estimate.
This WILL NOT result in a new policy, or change to an existing policy.

* Required Fields

Contact Information

Business Name*	Contact First Name*
Business Address*	Contact Last Name*
City*	Phone*
Province*	Phone 2
Postal Code*	Fax
Web Site	E-Mail*
Please specify your preferred method of contact:		Phone Email

Company Information

Years in Business

Type of business

Describe the major business activities of the organization

What is your current annual premium?

Insurance Information (Provide the following information for all Errors & Omission policies in the past 5 years)

Current Insurer	Expiry Date	Policy Number	Premium
			$
			$

Construction

Wall Type	Age of Building
Floor Type	Year Roof Updated
Wiring Type	Year Wiring Updated
Heating Type	Year Plumbing Updated
Plumbing Type	Year Heating Updated
Roof Type	Basement Finished	Yes No
Number of Storeys	Air Conditioning	Yes No
Total Square Feet	If yes, state Type
If building is over 50 years, has it been completely renovated in the past 30 years?		Yes No

Protection (Please fill in all applicable fields)

Fire Alarm System		Fire Alarm Monitoring
Burglary Alarm System		Burglar Alarm Monitoring
CO2 System		Contacts on Windows
# of Smoke Detectors		% Sprinklered
Distance to Hydrant		Distance to Fire Hall
Safe		Name of Alarm Company

Exposures

% Occupied by Insured		Other Occupancies
Manufacturing Exposures		Other Outside Exposures
Give Details

Coverage's - Property

Property	B/F or N/P	ACV or R/C	Deductible ($)	Limit ($)
Building
Contents
Stock
Equipment
Offices Contents
Options:
Flood		Sewer Back-up
Earthquake		By-Laws-Blanket
Same Site Clause Deletion (If RC selected)				Yes No

Coverage's - Inland Marine

Property	Limit ($)	Property	Limit ($)
Professional/Auditors Fees		Contractors Equipment
Accounts Receivable		Tool Floater
Valuable Papers		Installation Floater
Electronic Data Processing - Software		Transportation Floater
Electronic Data Processing - Hardware		Glass
Electronic Data Processing - Extra Expense		Exterior Sign / Antenna's / Satellite Dishes
Unnamed Locations		Deductible for this Section

Coverage's - Crime

Property	Limit ($)	Property	Limit ($)
Dishonesty Form (A)		Depositors Forgery
Dishonesty Form (B)		Safe Burglary
Broad Form Money and Securities		Medical Expenses
Inside/Outside Robbery		Deductible for this Section

Coverage's - Boiler & Machinery

Property	Limit ($)	Property	Limit ($)
Direct Damage		Hazardous Substance Clean-up
Production Machinery		Actual Loss Sustained
Air Conditioning		Profits
Electronic Equipment		Gross Earnings
Consequential Loss		Extra Expense
Ammonia Contamination		Rental Income
Expediting Expenses		Professional Fees/Auditors Fees
Deductible for this Section

Claims History

Claim	Date of Claim	Claim Payout	Details of Claim
1
2
3

Additional Comments

Please provide us with any additional information you feel would help us in providing you with an accurate quote.

by Internet

You get additional discounts if you insure your property and auto with the same company