Name
Contact person (if different)
Address - Street & City (Must reside in Manitoba, Canada)
Postal Code
Home phone
Business phone
Fax Number
E-mail (We can not respond unless you provide your E-mail address)
Date of birth: Day Month Year
Location(s) of business
Type of business
Number of years in business
Annual gross sales (needed in most cases to calculate a liability premium) $
Year building was built
Type of construction (frame, brick, fire resitive)
Is the building sprinklered? Yes No
Size (square footage) of building or space you rent
Do you have a burglar alarm? Yes No
Other occupancies (if any) in the building
Type of insurance required: All Risk Named Perils
Amounts of coverage required:
Building (if owned): $
Equipment: $
Stock: $
Business Interruption: $
Rental Income: $
Crime/Robbery hold-up: $
Liability: $
Claims Please detail all claims in the last 5 years:
© 2006 G.K. Braun Insurance Services Ltd.
