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COMMERCIAL RENEWAL APPLICATION Broker: Policy#: Expiry Date of Renewal: Named Insured: Change in name? If so, describe in full: Mailing address: BUILDING INFORMATION: Year built: # of Stories: CONSTRUCTION: Frame FOUNDATION: Concrete/Poured Concrete HEATING: Masonry Natural gas furnace Sq Footage: Non-Combustible Brick Hot water boiler Fire Resistive Stone Other (Describe): Post & Pier Oil furnace* Electric Preservative/Treated Lumber Woodstove* Other (Describe): Other (Describe): *please attach Questionnaire/Photos WIRING: Fuses Circuit Breakers PLUMBING: Copper: % UPDATE INFO: Heating: 60 amp PVC: % FIRE PROTECTION: Fire hydrant: Within 300m? Any Change in property values? Yes 200 amp Galvanized: Electrical: PRIVATE PROTECTION: Fire Extinguishers? 100 amp % Aluminum Wiring Other: % Plumbing: Roof: No Firehall: Within 5m/8km? Yes Yes No Smoke Detectors? Yes Knob & Tube wiring Describe: Yes No No Volunteer Monitored Alarm? Yes Paid No No Description of operations: # years in operation: Changes in operation? Annual Sales Yes No If so, describe in full: Expiring Term Next Term Canada U.S.A. Foreign (Specify Countries) No. of Employees: Gross Annual Payroll : $ Cost of Work Sublet : $ Coverage: As per expiring policy or Specify: Limit of Liability: As per expiring policy or Specify: Describe all losses paid or reserved that occurred or were reported during the past five years: DECLARATION I/We declare and warrant that after enquiry all statements and particulars contained in this Proposal and addenda are true and that no information whatsoever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this Proposal and should the above particulars alter in any way I/We will advise Underwriters as soon as practicable. I/We understand that failure to disclose any material facts that would be likely to influence the acceptance and assessment of the Proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect. I/We hereby agree and accept that this Declaration shall be the basis of the contract between both parties if entered into. I/We have been advised by the broker and consent to any information that may be perceived as personal information for collection, appropriate use, and disclosure of to third parties. Protection and Electronic Documents Act (PIPEDA) (Print Name of Proposed Insured) Signature of Insured & Title #100 1400 1st Street SW Calgary, AB T2R 0V8 Tel. : 1-855-745-1010 Fax : (403) 237-9976 [email protected] 4405, boulevard Lapinière (head office) Brossard, QC J4Z 3T5 Tel. : 1-855-745-1010 Fax : (450) 672-5533 Date 2550, boulevard Daniel-Johnson, #420 Laval, Québec H7T 2L1 Tel. : 1-855-745-1010 Fax : 450-681-7313 [email protected] 235 Yorkland Blvd., Suite 1100 Toronto, Ontario M2J 4Y8 Tel. : 1-855-745-1010 Fax: (416) 925-7260 [email protected]
