Commercial Liability Form

Contact First Name *

Contact Last Name *

Contact Phone *

Contact Email *

Business Name *

Street Address *

Apartment, suite, etc

City *

Province *

Postal Code *

Date the Business Started *

What industry is the business in? *

How many years experience do you have in this industry? *

Provide a brief explanation of operations.

How many full-time staff do you have?

How many part-time staff do you have?

What is the expected payroll this year?

What was the gross revenue last year?

What is the expected revenue this year?

What percentage of your sales is from the USA?

What percentage of your sales is from other parts of the globe?

Please break-down where your revenue comes from based on good or services offered

Do you carry out work through written contracts with every client?YesNo

Do you accept liability on behalf of a third-party?YesNo

Is the delivery of your good or service time critical?YesNo

Please Explain

Do you hire contractors to complete work?YesNo

How many physical locations does the business have?

If yes, are they required to have their own insurance?YesNo

Does it own any of these locations?YesNo

If so, do you need commercial property quoted as well? *YesNo

What amount of liability would you like?

What deductible would you like?

Do you have office supplies or equipment you want coverage for?YesNo

If yes, please explain

List all claims paid and outstanding during the past five years. State whether net of deductibles. What was the deductible in each policy year? *

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