Get an Auto Quote   |   Newsletters   |   Testimonials   |     1-800-661-1518

We realize insurance can be a complicated business! Please complete this section as best you can. If you have any concerns or if there are areas where you are not sure of then please leave blank and we'll contact you to review in greater detail.

Name:
Telephone #:
Fax #:
Website:
Email:
Contact Person:
Member of the
I require insurance starting on: (day/month/year)
Address:
City:
Postal Code:
Type of Business you have, please describe in detail:

Experience of Applicant (If more than One claim, please use the 'Comments' section below)
Number of years in Business:
Years of Experience in same industry:
Have you reported any Business Insurance Claims in the past 5 years: Yes No
If yes, date:
 What happened?
 Amount paid:
If yes, date:
 What happened?
 Amount paid:
If yes, date:
 What happened?
 Amount paid:
Has any Insurer cancelled or refused coverage in the last 5 years? YesNo
If yes, specify reason:
Your Current Insurer: Your Policy Number: Expiry Date:

Building Construction and Renovation, details of your business location
Do you rent or own the building: Rent Own Do you operate out of your residence?YesNo
Do you now insure your home with our brokerage?
Yes No 		If no, would you like a quote?
Yes No
Year built:
 Number of Storeys:
 Total building area:
Has Building been renovated? Yes No
If Yes, renovation upgrades: Electricity Year:
 Plumbing Year:
 Heating Year:
 Roof Year:
Building Construction: Fire resistive: Masonry non-combustible: Non-combustible:
  Masonry: Brick veneer: Frame/other:
Main heating system: If other, please describe:


  Summary of Coverage for Quotation    
Property Coverage Required Coverage Declined Deductible Limit
Building (replacement cost included)
Stock (actual cash value)
Contents (replacement cost included)
Leasehold Improvements
Signs
Office Computers / Laptops
Contractors Equipment
Tool Floater ($1,000 value or less)
Extensions of Coverage Coverage Required Coverage Declined    
Sewer Back up    
Earthquake / Flood    
Glass (exterior)    
Business Interruption Coverage Required Coverage Declined Deductible Limit
Actual loss sustained
Rental Income / Broad form
Profits / Broad form
Extra Expense
Crime Insurance Coverage Required Coverage Declined Deductible Limit
Loss inside / Outside the premises
Money, Securities Broad Form)
Employee dishonesty
Equipment Breakdown Coverage Required Coverage Declined Deductible Limit
Comprehensive form Including Air Conditioning / Refrigeration Equipment
Commercial General Liability        
Choose Limit $ 1Million
 $2 Million
 $3 Million
 $4 Million
  Coverage Required Coverage Declined Deductible Limit
Errors & Omissions
Directors & Officers
Pollution Environmental
Other Coverage Deductible Limit


Fire Protection
Are there hydrants within 1,000ft of your location:
Yes     No 		Does your location have automatic sprinklers:
Yes     No
Alarm Protection
Do you have an alarm system for burglary:
Yes      No      Central Location 		Do you have an alarm system for fire
Yes      No      Central Location
Sales/Revenue Volume
List type of slaes/opersations:
Canadian Business:
U.S Business:
Other Country:
Anticipated sales for next year:
Anticipated sales for next year:
Anticipated sales for next year:
Do you use Sub Contractors:
Yes     No 		If yes, describe:
Amount Sub contracted:
 Do you request proof that Sub Contractors are insured?
Yes     No
Additional Comments:
*DECLARATION / DISCLAIMER
The undersigned declares that all statements made in the Application and the information contained in documents submitted with it are true. Completion of this Application does not guarantee acceptance for insurance coverage and is for quotation purposes only. I understand by submitting this application, coverage is not bound unless confirmed in writing by Dan Lawrie Insurance Brokers Ltd. Signing of this document does not bind the Applicant to complete the insurance, but it is agreed that the Application shall be the basis of the contract, should a policy be issued. Dan Lawrie Insurance Brokers Ltd. is not responsible for applications not received due to transmitting errors. Please note a DLIB representative will contact you within 48 hours of receipt to confirm eligibility.
Applicant signature: Date:   (dd/mm/yy)