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Paying < $15K per year?
Paying > $15K per year?
Paying > $50K per year?
Want to cover Employees?
Want an industry expert?
Recruiting drivers?
Strategic Compensation & Directors and Officers
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Car Insurance
Home Insurance
Business Insurance
Boat Insurance
Trucking Insurance
RV Insurance
Travel Trailer Insurance
Overview
Car Insurance
Home Insurance
Business Insurance
Boat Insurance
Trucking Insurance
RV Insurance
Travel Trailer Insurance
Business Insurance
*
Mandatory field
Full legal name of insured:
*
Contact name:
*
Contact Title:
*
Email Address:
*
Total number of locations
(including address below):
Main Location Address:
*
City:
*
Province:
*
Postal Code:
*
Phone Number:
*
Fax Number:
Reason for call:
Referral by Hallmark customer
Referral by other
Current Hallmark Personal Lines or Life client
Looking for Competitive quote
Current Insurance cancelled or being cancelled
Is the business currently insured?
Yes
No
If yes, give Name of Insurer, Policy #, Expiry date & expiring Premium:
What type of business?
Retail
Office
Building ownership
Wholesale operation
Farm
Service Operation
Contractor
Garage operation
Manufacturer
Other
Please describe your operations in some level of detail:
What is the annual revenue?
Up to $50 000
$51 000 to $100 000
$101 000 to $500 000
$501 000 to $1 000 000
Over $1 000 000
How many years in business?
< 1 years
1 - 5 years
> 5 years
What is the annual payroll?
Up to $50 000
$51 000 to $100 000
$101 000 to $500 000
$501 000 to $1 000 000
Over $1 000 000
Do you sell products or services into the USA?
Yes
No
What coverages do you feel you require?
Have you been speaking to other brokers about arranging this insurance?
Yes
No
Have there been any insurance
claims in the last 3 years?
Yes
No
If yes, list all claims reported in the last 5 years showing:
i) Date of loss
ii) Amount paid
iii) reserve amounts.
(Include all claims that were closed without any payment)
Age of main location building:
< 1 year
1 - 20 years
20 - 35 years
> 35 years
Construction of main building:
Frame
Masonry
Non-Combustible
Fire Resistive
Is the building sprinklered?
Yes
No
If building owned, what is total area?
< 5 000
5 000 - 10 000
> 10 000
(sq. ft.)
How many stories in building you own?
1
2
3 - 5
6 - 10
> 10
If a tenant, how much area do you occupy?
< 5 000
5 000 - 10 000
> 10 000
(sq. ft.)
Are you the only tenant?
Yes
No
Is there a hydrant within 500 ft.
(150 metres)?
Yes
No
Is there a fire hall within 3 miles
(5 kms)?
Yes
No
Additional Comments:
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