How did you hear about us?
(choose one)
Company website
Existing Client
Family Referral
Port Perry Tribune
Reader's Choice Award
Referral
Risky Business Article
Uxbridge Tribune
Walk-in
Website
Yellow Pages
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Preferred Method of Contact:
(choose one)
Email
Phone
Age of building:
(choose one)
< 1 year
1 - 20 yrs
> 35 yrs
Construction of Building:
(choose one)
frame
masonry
non-combustible
fire resistive
Is the building sprinklered:
How much area do you occupy:
(choose one)
<5,000 sq ft
5,000 - 10,000 sq ft
>10,000 sq ft
Are you the only tenant:
Is there a hydrant within 500 ft (150 metres):
Is there a fire hall within 3 miles (5 kms):
Has insurance ever been denied or cancelled :
What type of business :
(choose one)
retail
office
building ownership
wholesale operation
farm
service operation
contractor
garage operation
manufacturer
other
How many years in the business :
(choose one)
< 1 year
1 - 5 years
> 5 years
Has there been any insurance claims in the last 3 years:
(choose one)
no
< = 2
>= 3
What are the annual receipts :
(choose one)
up to 50,000
51,000 to 100,000
101,000 to 500,000
501,000 to 1,000,000
over 1,000,000
What is the annual payroll:
(choose one)
up to 50,000
51,000 to 100,000
101,000 to 500,000
501,000 to 1,000,000
over 1,000,000
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