Brokerage Information:
Office:
Marketer:
Producer:


Client Information:
Name: Account #:    
Street: Phone: Fax:
City: Country: Prov:
Postal Cd:        
Web Site: E-mail:    


Additional Phone Numbers:
Main   Direct   Toll   Fax   Pager  Cell   Home Other
Main   Direct   Toll   Fax   Pager  Cell   Home Other
Main   Direct   Toll   Fax   Pager  Cell   Home Other


Client Contacts:

Position: Accountant, CEO, Insured, Manager, Owner, President, Principal Partner, secretary, Vice-President
Last Name First Name Mr./Ms./Dr./ Position Phone Email Other

 

Retail Business Operations:


Industry Code:
Description of Operations:


     
Liability Rating Information:

  
BUSINESS INFORMATION:

      
Business since: Full-time Employees:    
Part-time Employees:


Cover by WCB


  
EXPOSURE RATING BASIS:

      
Annual gross receipts: US %:    
Canadian %:   Foreign %:    


PAYROLL:

      
Annual Payroll:        
   
Liquor Liability: Is there any liquor liability: yes   no  
  Receipts Splits:   Liquor $: Food $: Other $:

Additional notes:  


Building Ownership Operations:

Street: City: Province:
Postal Code: # Stories: Age:
Total Sq Ft of building: Gross Rents: Insured Value:
Occupancies:


Claims Information:


Loss Date : Type: Description:


Miscellaneous:

Notes:   
Special circumstance concerning this policy/application that company should know.
Has any insurer cancelled, declined or refused to issue insurance
to the applicant within the past 5 years?    yes   no

Broker Declaration: I have known the client since: This Business/Client is new to my office
       
Policy Information: Period of coverage: From:    To:
 
Package:
       
Broker/Applicant: *application must be fully completed to ensure quotation
       
Payment Information: Company Bill
Broker Agent/Bill
Other

  


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