Commercial Insurance Details





PART 1: Customer Information

Quote Needed By:


Insured Name: (required)


Phone Number: (required)


Mailing Address: (required)


Contact Name: (required)


Email: (required)


Website:


How did you hear about us?

Type of Business:


If “Other”, please describe:

Detailed description of all business/operations:


Number of years in business:


Experience in related business:

INSURANCE HISTORY:
Previous Insurance Company & Policy Number:


Have you ever been declined/cancelled/refused Insurance?
 Yes No
If “Yes”, why?

LIST ALL LOSSES AND CLAIMS IN THE LAST 5 YEARS:
#1.




#2.




#3.




What preventative measures have been taken after the losses?


PART 2: Property Details

Location #:


Risk Address:


Loss Payee:


Risk Type:
 Building Owner Tenant Other
If “Other”, please describe:


Building Type:


Dwelling Age:


Number of stories:


Basement:
 Yes No
Square Footage of Building:


Square Footage Occupied by Insured:


Other Occupants Business Types:


Condition of Dwelling:  Good Fair
Construction:


If “Other”, please describe:


Sprinklered?
 Yes No
Fire Extinguishers?
 Yes No
If “Yes”, how many:


External Fire Protection:
 Hydrant within 1,000 feet Fire hall within 8km Unprotected
Burglary:
 Local Alarm Central Motorized Alarm
Alarm Company is:


Other Protection:
 Bars on Rear Window Dead Locks on Back Door Other
If “Other”, please describe:


Heating Type:


Electrical Type:


Roof Type:


Plumbing Type:


Updates:
Heating Year:


Electrical Year:


Roof Year:


Plumbing Year:


Inspections Done on Building:


Inspections done by Whom and When:


Adjacent Exposures (**When facing the Risk**)
 Front Rear Left Right
Other Information:


PART 3: Other Information

No. of Employees:
Office/Clerical:


Outside Salespersons:


Service/Repair:


Off Premises:


Total Annual Gross Receipts:


Total Annual Payroll:


U.S. Exposure?
 Yes No
Total Annual Gross Receipts for U.S.:


Foreign Exposure?
 Yes No
Total Annual Gross Receipts (foreign):


Subcontracted Work?
 Yes No
Type of Subcontracted Work:


Amount Subcontracted:


Are sub-contractors checked for their own Liability Policy in Force?
 Yes No Sometimes
Safe on Premises?
 Yes No
Type/Serial#:


Is the Safe Fire Resistant?
 Yes No
Is the Safe Locked at all times?
 Yes No
Process Hazards:
 Welding Soldering Spray Painting (open area) Spray Painting (approved booth) Flammable Liquids Fiber Glassing Woodworking Explosives Gases

Additional Information on Special Hazards, Processes and Safeguards:
Equipment Breakdown:
 Computers Boilers Electrical Switchgear Refrigeration Units Electrical Motors Air Compressors Telephone Ceased Pressure Vessels Air Conditioners Transformers Other
If “Other”, please describe:


Other information:


PART 4: Policy Limits

Commercial General Liability:
Products & Completed Operations:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Commercial General Liability:
Premesis Liability Only:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Tenants Legal Liability:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Non Owned Auto:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Building:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Equipment (machinery, etc.):
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Office Content/Office Equipment:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
General Contents:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Stock:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
EDP Equipment ON Premesis:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Laptops/EDP to Schedule OFF Premesis:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Software:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Tool Floater OFF Premesis:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Multi-Peril Extension Endorsement:
Limit Required:
 Yes No
All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Accounts Receivable:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Valuable Papers:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Tenants Improvements (Leasehold Improvements):
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Annual Rental Income:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
In Transit?
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Blanket Glass:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Installation Floater Stock/Prop Job Sites?
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Work in Progress?
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Stock… Peak Periods?
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
High Period Months:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Signs Not Attached – Inside:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Signs Attached to Building – Outside:
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Business Interruption (Profits, Gross Earnings, NoCo, 50co, 80co)
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Extra Expense
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Auditors Fees
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Boiler & Machinery (Equipment Breakdown)
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Consequential Loss (Foil Spoilage, etc.)
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Crime Coverage (Money/Securities):
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Comp DDD Bond:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Home Custodian?:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Sewer Back-up:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Earthquake:
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


————————————————————
Flood
 Yes No
Limit Required:


All Risk:


Replacement Cost:


Actual Cash Value:


PART 5: Additional Information

Additional Information Required or additional notes for the Broker/Underwriter:

The above information is correct to the best of my knowledge:  I Confirm


Download Quote as PDF


If you would prefer, download this PDF file, print and fill out quote details.
Fax or email to Chambers Olson Ltd. when you are ready to submit: 604-734-7644 or jollean@chambersolsonltd.com.

Questions?

If you have any questions please feel free to call us at 604-734-2288 or email info@chambersolsonltd.com