Commercial Insurance Form

CONTACT INFORMATION

Company Name^*	Contact First Name^*
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

Number of Employees

Approx. Annual Revenue

Number of Locations

Current Insurance Company^*(enter "none" if you are not currently insured)

Current Policy Number^*(enter "none" if you do not have a policy number)

Expiry Date

What is your current annual premium?	$
Why are you looking for a new insurer or broker?

Please provide a brief description on the nature of your business activities:

INSURANCE INFORMATION

Please select the type of quote required
Please check off required areas for coverage:
Building		Office Contents
General Liability		Business Interruption
Commercial Auto/Fleet		Crime
Boiler & Machinery		Garage Auto
Computer & Software		Surety/Bonding
Directors & Officers		Excess Umbrella
Environmental		Employee Group
Employee Benefits		Other (specify)

ADDITIONAL COMMENTS

Please take a moment to tell us how you heard about us:

THANK YOU