| Age of building: |
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| Construction of building: |
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| Years Continuously Insured: |
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| Is the building sprinklered? |
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| How much area do you occupy? |
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| Are you the only tenant? |
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| Is there a hydrant within 500 ft. (150 metres)? |
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| Is there a fire hall within 3 miles (5 kms)? |
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| Has insurance ever been denied or canceled? |
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| What type of business? |
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| How many years in the business? |
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| Have there been any insurance claims in the last 3 years? |
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| What are the annual receipts? |
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| What is the annual payroll? |
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| How did you hear about us? |
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