Commercial Insurance Application
	RISK IDENTIFICATION
	Agent/Broker:
	Policy Number:
	Name of Applicant:
	Name of Principal(s):
	Date of Incorporation (mm/dd/yy):
	Mailing Address:
	Postal Code:
	Telephone Number:
	Contact Person:
	Period of Insurance (From):
	Period of Insurance (To):
	Risk Location (if different from applicant's address):
	Postal Code of Risk Location:
	UNDERWRITING INFORMATION
	Storey:
	Area:	Square Feet
	Age/Year Built:
	Construction:
	Wall:
	Roof:
	Heating:
	Electrical:
	Extinguishers:
	Sprinklered:	Yes No
	Burglary Alarm:	Local Monitored If monitored, by whom:
	Public Fire Protection:	Within 300M of Hydrants: Yes No Within 8KM of Fire Hall: Yes No
	Applicant's Occupancy & Operation:
	Other Occupancies:
	Number of Emloyees:
	Estimated Annual Wages:
	Estimated Annual Gross Receipts:	$
	Liquor Sales:	%
	Any Sales or Operations Outside B.C.:	Yes No
	Previous Losses (Past 5 years):
	Previous Insurer & Policy Number:
	Has any Insurer cancelled or refused insurance during the past 5 years:	Yes No If yes, describe:
	Loss Payee(s), if any:
	Additional Information:
	COVERAGES AND LIMITS
	PROPERTY COVERAGES AMOUNT/LIMIT RATE PREMIUM Building $ @ $ Contents $ @ $ Specified Contents: $ @ $ Other Property: $ @ $
		Limited Form Broad Form Co-insurance % Deductible $ Replacement Cost (Except Stock) Earthquake - Deductible % Flood - Deductible $ Sewer Backup - Deductible $
	BUSINESS INTERRUPTION COVERAGES AMOUNT/LIMIT RATE PREMIUM Business Interruption $ @ $
		Co-insurance % Gross Earnings Form Monthly Earnings Form Extra Expenses Form Rent Value Form Profits Form Deductible $
	CRIME COVERAGES AMOUNT/LIMIT RATE PREMIUM In/Out Robbery $ @ $ Damages to Premises $ @ $ Deductible $ $ @ $ Other: $ @ $
	LIABILITY COVERAGES AMOUNT/LIMIT RATE PREMIUM Commercial General Liability $ @ $ Owners', Landlords', & Tenants' Liability $ @ $ Tenants Legal Liabiliity $ @ $ Deductible $ Non-owned Automobile Products Completed Operations Other: $ @ $
	Total Premium:   $