|
Name
of the company:
(include the corporate or
Quebec Inc. name) |
|
| Name
of the owner: |
|
| First
name of the owner: |
|
| Date
of birth: |
|
| Business
address:
(include postal code) |
|
Postal
address, if different:
(include postal code) |
|
| Telephones: |
|
| Email: |
|
Co-owners,
if any:
(provide details as above) |
|
| Number
of years in operation: |
|
| Number
of years experience in the field: |
|
Type
of operation:
(provide a full description) |
|
| Annual
gross receipts: |
|
| Number
of employees and total gross payroll: |
|
Present
insurer:
(name of the insurance company,
policy number and expiry date) |
|
| Alarm
system connected to central station: |
|
| Distance
to a fire hydrant: |
|
| Proximity
to a fire department: |
|
Sales
outside Québec:
(provide details under Special
considerations) |
|
| Criminal
antecedants: |
|
Claims
or incidents in the past 6 years:
(provide dates, circumstances,
amounts) |
|
| Building's
owner or tenant: |
|
Describe
building:
(number of stories, construction,
age, etc.) |
|
Name
and address of mortgagee:
(include the postal code)
|
|
| Current
amount of the mortgage, if applicable: |
|
Other
tenants in the building, if any:
(specify the activities of
each) |
|
Type
of heating:
|
|
Neighbouring
buildings and businesses:
(describe and specify distance
away in feet) |
|
Restaurants
or bars in proximity:
(provide details in radius
of 1000 feet) |
|
Cancellation
or non-renewal of an insurance policy in
the past:
(provide the details in Special
consideration, if applicable) |
|
Coverages
and amounts requested:
(minimum deductible $500
for A,B,C,D,E.)
|
|
| Amounts
requested: |
|
| Deductible
requested: |
|
| Special
considerations: |
|
| Digital
photos: |
|
|
|
|
