Commercial Insurance Quotation Application

COMMERCIAL INSURANCE QUOTATION APPLICATION

Key Insurance Services Suite 105 – 200 West Esplanade. North Vancouver, B.C. V7M 1A4

Ph: 604-982-3111 Fax: 604-982-3112

BUSINESS NAME:
OWNER’S NAME(S): / YEARS IN BUSINESS:
YRS. OF EXPERIENCE:
MAILING ADDRESS: /

POSTAL CODE

PHONE NUMBERS: / BUS: / CELL: / FAX:
EMAIL ADDRESS:
LOCATION ADDRESS:
(If different than mailing address) / POSTAL CODE
OCCUPANCY:
OCCUPANCY OTHERS:
ADJACENT RISKS:
OPERATIONS:
Attach info – brochures,
Website, etc.
REQUIRED:
Check Yes or No - if the
Client does do any work
involving the items listed: / Demolition, Tunneling, Drilling, Pesticides, Welding, Airports, Pile Driving, Pressure Washing, Blasting, Railroads, Spray Painting, Snow Removal, Unlicensed Vehicles, Ships, Docks, Gasoline, Propane Gas,
or Natural Gas.
YES NO (If yes, supply a good description of this work done)
BUILDING: / Year Built: / Stories: / Frame, or Mixed Const.: / Masonry: / Concrete:
AREA –square feet: / Total Area: / Applicant’s area: / Basement:
FOUNDATION: / Concrete: / Posts: / Wood: / None: / U/G Parking?
ROOF: / Flat:

Peak:

/ CONTRUCTION: /

Wood Joist:

/ Metal: / FINISH: / T & G:
Concrete: / Other: / Steel Deck:
Shingle:
Other:
PLUMBING: / Copper: Copper/Plastic/PVC Mix: Galvanized:
BUILDING CONDITION: / Excellent: / Good: / Average: / Poor: / Modern: / Old:
YEAR OF
UPDATING: (if over 25 yrs.) / Plumbing:
Complete or Partial: / Heating:
Complete or Partial: / Electrical:
Complete or Partial: / Roof:
Complete or Partial:

COMMON HAZARDS

ELECTRICAL: / Copper Wiring: / Circuit Breakers: / Fuses: / Aluminum Wiring:
Knob & Tube:
HEATING: / FUEL: / Gas: / Oil: / Electric: / Coal: / Wood: / No Heat:
TYPE: / Forced Air: / Boiler: / Radiant: / HVAC:

GENERAL

PUBLIC FIRE
PROTECTION: / Fire Hall
Public: / Fire Hall
Volunteer: / Hydrant within: 300 Meters
yes: no: / Firehall within: 8 Kilometers
yes: no:
PRIVATE FIRE
PROTECTION: / Portable
Fire Extingushers / Local:
Fire Alarm / Monitored:
Fire Alarm / Monitored by: / Building Fire
Sprinklers:
BURGLARY PROTECT: / Deadbolts: / Bars: /

Security Cameras:

/ Local:
Burglar
Alarm / Monitored:
Burglar
Alarm / Monitored by:
LIABILITY: / Gross receipts: $ / Canada: % / USA% / Other: %
Manufacturing:% / Installation:% / Wholesale/Dist:% / Retail:%
Contracting:% / Consulting:% / Subcontracted:%
Gross payroll: / Number of employees:
Any Products Directly Imported from Outside Canada and the USA? yes: no:
Employees covered by WCB? yes: no:
Is there any Liquor Liability? yes: no: - If yes, Liquor Receipts: $
RISK HISTORY5 yr. Loss history: / Have there been any claims or losses in the past five years? yes: no:
Date: / Cause: / Amount: $
Use a separate note, if there has been more than one claim or loss.
Cancellation: / Any Insurer ever declined, cancelled, or refused renewal in the past 5 years? yes: no:
If yes, provide details:
CURRENT INSURANCE: / Company: / Policy No: / Exp. Date:

Current Premium:$ (Insurance Company Underwriters all want to know the current premium and will tell us quickly if they can or cannot beat a rate).

PRODUCER: / Name: / Date:
DATE NEW POLICY REQUIRED:(MM/DD/YYYY) Minimum 30 days in advance is best for Quotations.

COVERAGES

/

LIMITS

/ LIST ANY OTHER COVERAGE & LIMIT BELOW:
BUILDING:
STOCK:
EQUIPMENT:
TENANT’S IMPROVEMENTS:
OFFICE CONTENTS:
EXTRA EXPENSE:
BUSINESS INTERRUPTION: / Quote: yes: no:
RENTAL INCOME:
FLOOD:
EARTHQUAKE: / Quote: yes: no:
EDP/COMPUTER:
Misc. PROPERTY FLOATER:
TOOL FLOATER:
CRIME; Robbery & Hold-up:
GLASS CONTRACT: / Quote: yes: no:
BOILER & MACHINERY: / Quote: yes: no:
COMMERCIAL GENERAL
LIABILITY: / Limit Required: $_
TENANTS LEGAL LIABILITY: / Limit Required: $_
SPECIAL COVERAGES OR ENDORSEMENTS: Send Request.
ADDITIONAL INSURED(S): / LOSS PAYEE(S):
DATE QUOTED: (MM/DD/YYYY) / DATE COVERAGE BOUND: (MM/DD/YYYY)
AUTHORIZED BY: (NAME) / AUTHORIZED SIGNATURE: ______
APPLICANT’S SIGNATURE: ______DATE: ______

NOTES: