General Liability Application Submission of this information does not represent a binding of any insurance contract or agreement. Additional information may be required in order to get an accurate quote of insurance. Name First Last Name of Your BusinessEmail PhoneHave You Ever Had Any Claims? Yes No If You Have Had Claims, Please Describe How Many, When They Occured, What Was The Payout? Is the Claim Still Open? What Has Been Done To Prevent Such Claims In The Future:Are You Currently Insured? Yes No Current Insurance Company Name:How Many Years Have You Been Insured With them?How Many Years Of Experience Do You Have in This Line of Business?Address Location Of Your Business Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Please Describe to Us Your Business Operations:What Is Your Annual Revenue? Or Estimated Annual RevenueInsurance companies use this as a rating criteria to see how large your business is and what the exposure can be. If this is a new business, you should provide an estimate what the gross sales might be.Are Any Of Your Sales From Outside Canada? Yes No Which Countries?What % of Sales From Each Country?Are Any Products You Sell Imported or Prepared from Outside North America? Yes No How Many Employees Do You Have?Do You Use Any Sub-Contractors ? Yes No What % of Sales is Derived from Your Sub-Contractors?Do You Require All Sub-Contractors to Carry At Least $2 Million in Commercial General Liability Insurance? Yes No What Limits of Liability Are you Looking For? $2 Million $5 Million Higher Consent* I agree to the Privacy Policy and acknowledge the Disclosure Statement.
