Business Insurance

Name:

Email Address:

Address:

City:

Province:

Postal Code:

Phone Number:

Age of Building:

Construction of building:

Is the building sprinklered:

Yes

No

How much area do you occupy:

Are you the only tenant:

Yes

No

Is there a hydrant within 500 ft. (150 metres):

Yes

No

Is there a fire hall within 3 miles (5 kms):

Yes

No

Has insurance ever been denied or canceled:

Yes

No

What type of business:

How many years in the business:

Have there been any insurance claims in the last 3 years:

What are the annual receipts:

What is the annual payroll:

Your Protection is Our Business

Atrens-Counsel Insurance Brokers, a division of Arthur J. Gallagher Canada Limited.