Name:

Address:

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Age of building:     Less than 1 year1 to 20 years20 to 35 yearsMore than 35 years

Construction of building:    FrameMasonryNon-CombustibleFire Resistive

Is the building sprinklered? YesNo

How much area do you occupy?     Less than 5,0005,000 to 10,000More than 10,000

Are you the only tenant? YesNo

Is there a hydrant within 500 ft. (150 metres)? YesNo

Is there a fire hall within 3 miles (5 kms)? YesNo

Has insurance ever been denied or canceled? YesNo

What type of business?     RetailOfficeBuilding ownershipWholesale operationFarmService OperationContractorGarage operationManufacturerOther

How many years in the business?    Less than 1 years1 to 5 yearsMore than 5 years

Have there been any insurance
claims in the last 3 years?     No<= 2>= 3

What are the annual receipts?    Up to $50,000$51,000 to $100,000$101,000 to $500,000$501,000 to $1,000,000Over $1,000,000

What is the annual payroll?     Up to $50,000$51,000 to $100,000$101,000 to $500,000$501,000 to $1,000,000Over $1,000,000