Van Dyk Insurance Brokers Ltd.

Commercial Insurance - Quote Form

Please fill in all of the fields and then submit the form.

General Information

Business name:

Name of principal:

Address:

Phone number:
(Format: ###-###-####)

E-mail address:

Postal code:
(Format: C#C#C#)

Expiry date of current policy:
(Format: dd/mm/yyyy)

Eligibility

Nature of business / occupancy:

Description of business:

Has the business had any claims in the last 3 years?

Yes No

Has the applicant had any previous insurance declined or cancelled?

Yes No

Does the floor area exceed 20,000 sq. ft.?

Yes No

Is this a seasonal business?

Yes No

Do gross sales exceed $3 million?

Yes No

Does the business sell or export goods or services outside of Canada?

Yes No

Is the building older than 35 years?

Yes No

Building Updates

Plumbing: (Format: yyyy)
Roof: (Format: yyyy)
Electrical: (Format: yyyy)
⇒	Main service
⇒	Fuses or breakers:
⇒	Type of wiring:	Romex NMD (plastic) BX

Is the business, in whole or part, for manufacturing or processing?

Yes No

Is the business a wholesaler?

Yes No

Does the business sell second-hand goods?

Yes No

Is the business located in a hotel?

Yes No

Does the business have an approved burglar alarm system?

Yes No

Physical Risk Information

Is the building owned by the applicant?

Yes No

Building construction:

Does the building have a sprinkler?

Yes No

Percent sprinkled (0 to 100):

Number of employees (including principals):

Year built:
(Format: yyyy)

Construction

Walls:

Solid brick	Concrete block	Frame
Steel	Reinforced concrete	Other:

Roof:

Wood

Steel

Other:

Roof surface:

Patent

Metal

Other:

Floors:

Wood

Concrete

Other:

Does the building have a basement?

Yes No

Basement:

Wood

Concrete

Concrete block

Heating

Heating:

Forced Hot Air	Hot Water	Steam
Gas suspended units

Chimney

Chimney:

Fuel

Fuel:

Gas

Electric

Wood / Coal

Oil Tank

Does the building have an oil tank?

Yes No

Age of oil tank:

Special Hazards

Special hazards:

Burglary

Windows barred or screened?

Yes No

Deadbolts?

Yes No

Alarm system?

Yes No

Is the alarm system ULC approved?

Yes No

Type of alarm system:

Coverage

Liability amount:

Building amount:

Contents amount:

Professional liability required?

Yes No

For...

19 Royal Oak Drive, Brantford, Ontario, N3R 7P2, Canada

Phone	(519) 758-1700
Toll-free	(800) 437-9555