YOUR LOCATION

Building Owned? Leased? Date occupied by you:

If leased, indicate name of Landlord:

If owned and leased to others, amount of annual rent $

Loss Payee (Mortgagee) - (name & address)

Total sq. ftg. % office % warehouse / other

Other occupancies of building: (name of tenants)

Year Built: Number of Stories: Sprinklers? Yes No

Construction: concrete (HCB) and steel brick wood or frame combination/mixed
If combination, indicate % of each approx.

Fire Hydrant within 300m? Yes No Fire Hall within 5km? Yes No

Approximate replacement value of building: $

YOUR BUSINESS

Annual Estimated Receipts: $

Date Business Established # of Employees

Values: Computers & related equip. $

Office Furniture & Equipment $ Stock $

Other Equipment $ Other $

Description of operations on premises:

Comments:

CONTACT INFORMATION

Contact Name:
Phone: Fax:
Email Address: