Describe All Operations on the Premises:
(specify the types of businesses and describe all related activity)

If business is conducted from detached building on premises, describe;

Construction:		Year Built:
Heating:		Area:

Claims in the last 3 years: None, or See List Below

Date of loss (d/m/y)	Cause of loss

Number of employees:

If tutor or music/art teacher, indicate number of students :

Annual gross receipts (sales or fee's):
(if new venture, estimate receipts)

State year business started:

Number of rooms used:

For Bed & Breakfast, Number of bedrooms:

Area used:

Percentage from off premises service, installation, repair or delivery: %

Occupancy - home business: Indicate extent of client visits to premises: Not at all Occasionally to pickup/drop off goods only Often to buy goods and/or services Remain on the premises for duration of business activity

Describe off premises operations:

If sales, describe type of product sold:

If crafts are made, describe products:

Is the home... Protected - hydrant within 500 feet (152m) Semi-protected - firehall within 8 miles (13km) Unprotected - all others Burglary alarm - local Burglary alarm - monitored

Burglary Protection: Bars Safe Other - describe

Coverage Required:

Equipment $

Stock + $

Total Contents = $

Farm and Home Business Liability: $1,000,000 $2,000,000 $5,000,000

Professional Liability Required?

Previous insurer:
Name:
Policy Number: Expiry Date: (d/m/y)

Has any insurer cancelled, declined, or refused to renew or issue any commercial insurance to the applicant within the past 5 years? No Yes
If yes, provide details: