Dyck Insurance

Name: *

Email Address: *

Phone Number: *

Address: *

City: *

Province: *

Postal Code: *

Age of building: < 1 year 1-20 years 20-35 years > 35 years *

Construction of building: Frame Masonry Non Combustible Fire Resistive *

Is the building sprinklered?: Yes No *

How much area do you occupy?: < 5,000 5,000-10,000 > 10,000 *

Are you the only tenant?: Yes No *

Is there a hydrant within 500 ft. (150 metres)?: Yes No *

Is there a fire hall within 3 miles (5 kms)?: Yes No *

Has insurance ever been denied or cancelled?: Yes No *

What type of business?: Retail Office Building Ownership Wholesale Operation Farm Service Operation Contractor Garage Operation Manufacturer Other *

How many years in the business?: < 1 year 1-5 years > 5 years *

Have there been any insurance claims in the last 3 years?: no <= 2 >= 3 *

What are the annual receipts?: Up to $50,000 $51,000 to $100,000 $101,000 to $500,000 $501,000 to $1,000,000 Over $1,000,000 *

What is the annual payroll?: Up to $50,000 $51,000 to $100,000 $101,000 to $500,000 $501,000 to $1,000,000 Over $1,000,000 *