Orangeville Insurance Services Ltd. - Personal & Commercial Insurance

Name:
Date of Birth:	Date and time
Co-Applicant Name:
Co-Applicant d.o.b.:	Date and time
Email Address:
Address:
City:
Province:
Postal Code:
Phone Number:
Age of Building:
Construction of building:
Years continuously insured:
Is the building sprinklered:	YesNo
How much area do you occupy:
Are you the only tenant:	YesNo
Is there a hydrant within 500 ft. (150 metres):	YesNo
Is there a fire hall within 3 miles (5 kms):	YesNo
Has insurance ever been denied or canceled:	YesNo
What type of business:
How many years in the business:
Have there been any insurance claims in the last 6 years:
What are the annual receipts:
What is the annual payroll:
Current Limits of Building Coverage:
Current Limits of Contents Coverage:
Current Limits of Stock Coverage:
Current Limits of Equipment Coverage:
Current Limits of Liability Coverage:

Commercial Insurance