Commercial Insurance Quick Quote Form

All estimates confidential, and for our company use only: no access is given to outside mailing lists or agencies. Commercial Insurance is a complex and varied field.... if you need assistance or have a situation not covered by this form, please give us a phone call.

Applicant Name:
Contact Names:
Mailing Address:
City:
Province:
Postal Code:
Work Phone #:
Work Fax #:
Home Phone #:
Home Fax #:
Cellular Phone #:
E-mail address:	(Required)

Building Information

If you own several buildings or businesses, please fill out a separate Form for each... Thank you!

Are you a Commercial Tenant Commercial Condominium Unit Owner or Commercial Building Owner

Are you seeking Insurance for:

a Building/Strata Unit
Business only
Building/Strata Unit and Business

Address of building to be insured:
Year Building constructed:
Type of construction:	Frame:
	Solid Brick:
	Hollow Concrete Brick:
	Concrete:
	Other:Specify if Other:
Number of stories:
Square Footage of building:
Square Footage of your business premises:
Roof Material:
Heating:	Furnace Oil Furnace Gas
	Electric Heat Other:
Electrical::	Breakers Fuses
	Both Breakers & Fuses
Dead Bolt Locks	Yes No
Bars on Windows:	Yes No
Local burglar alarm:	Yes No
Monitored burglar alarm:	Yes No
Motion Detectors:	YesNo
Dedicated Line for Alarm:	Yes No
Monitoring Company:
Sprinkler System in building:	YesNo
Fire Hydrants within 1000 ft:	Yes No
Firehall within 5 miles:	Yes No

Business Information

Name of Business to be insured:
Type of Business
Number of employees:
How long in Business:
Do you Rent or Own:	Rent Own
Amount of Monthly Rent/Mortgage Payments:
Gross Receipts :
Ordinary Payroll, Annual:
Important Payroll, Annual:
Cost of Goods Sold, Annual:
Gross Earnings:
Process Hazards:
Hazardous materials:
Any goods Exported?:	Yes No
Where Goods Exported:
List the other businesses in your Building :

List Businesses in adjacent buildings	Front Exposure:
	Left Exposure:
	Right Exposure:
	Rear Exposure:

General

Previous/Current Broker:
Previous/Current Insurer:
Previous Policy no:
Expiry Date of present policy:
Should you decide to be insured by our company,
what date would you need your coverage to begin?
Have you ever been cancelled, declined or been refused renewal?	Yes No
If yes, please explain.
Have you had any Losses (Claimed or
Unclaimed) during the past 5 years?	Yes No

If yes, what was the Date(s), Amounts of Loss(es), Kind of Loss(es), and state if you filed a claim:
(Please List information on losses even if you did not file a claim or your claim was not settled)

Date of Loss	Amount of Loss	Kind of Loss	Did you File a Claim?
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No

Amount of Coverage

Coverage on Building (Building Owners Only):
Coverage on Computer Equipment and Software:
Coverage on other Equipment:
Coverage on Tenants Improvements:
Replacement cost or Actual Cash Value:	Replacement CostActual Cash Value
Coverage on Stock:
Type of Coverage:	Fire & Extended All Risk
Coverage on Goods in transit:
Coverage on Goods in any other location:
Coverage on Goods in custody of salesman:
Gross Earnings Coverage:	No coinsurance 50% coinsurance clause 80% coinsurance clause
Rental Income Coverage:	50% coinsurance clause 100% coinsurance clause
Coverage on Extra expense (due to business interruption):
Coverage on Profits form (Business interruption):
Coverage for Consequential Loss (Loss resulting from change of temperature of contents of freezers, fridges, coolers, etc.)
Do you wish coverage for interruption of electric power to be included?	Yes No
Coverage on Earthquake:	Yes No
Coverage on Flood:	Yes No
Coverage on Sewer Backup:	Yes No
Coverage for Robbery (Holdup):
Coverage on General Legal Liability:	1 million 2 million 3 million 5 million none Other:
Do you want Product liability or Completed operations liability included?	Yes No
Coverage on Professional Liability (errors & omissions):	1 million 2 million 3 million 5 million none Other:
(Tenants only) Coverage on Tenants Legal Liability (in the event your landlord sues you for damage to the portion of the building you rent or lease):	$100,000 $200,000 Other:
Coverage on Glass:	Yes No
Glass Square Footage:	Single Pane:Double Pane:
Bond amount:
Coverage on Boiler and Machinery:
Type of Coverage on Boiler and Machinery:	Broad Form: Comprehensive Form:
Coverage on Air Conditioning:	Yes No
Coverage on Valuable Papers:

If you have any questions or comments, please enter here::

Location

2425 Burrard Street
Vancouver, BC
V6J 3J3

Contact Us
Tel: (604) 736–7668
Fax: (604) 736–4375
Send us a message

Office Hours
Monday to Friday
9:00 am – 7:00 pm
Saturday
10:00 am – 4:00 pm