How did you hear about us? |
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Name: |
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Address: |
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City: |
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Province: |
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Postal Code: |
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Phone Number: |
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Email Address: |
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Preferred Method of Contact: |
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Age of building: |
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Construction of Building: |
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Is the building sprinklered: |
Yes
No |
How much area do you occupy: |
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Are you the only tenant: |
Yes
No |
Is there a hydrant within 500 ft (150 metres): |
Yes
No |
Is there a fire hall within 3 miles (5 kms): |
Yes
No |
Has insurance ever been denied or cancelled : |
Yes
No |
What type of business : |
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How many years in the business : |
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Has there been any insurance claims in the last 3 years: |
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What are the annual receipts : |
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What is the annual payroll: |
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Comments: |
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