Business Insurance - HIFA Insurance Brokers

Business Insurance Quote Request

Business details:

Legal name

Operating name (if any)

Address

Street address

Unit#, etc.

City

Province

Postal code

Main phone

Main email

Website

Legal entity:

Sole proprietorship

Partnership

Incorporation

Other

Legal entity other

Contact person details:

First name

Last name

Contact person's phone no.

Contact person's email

Insurance details:

Current insurance company name (if applicable)

Current insurance policy number (if applicable)

Effective/renewal date

If renewal was not being offered, please explain.

Describe all claims, including any outstanding, and fees for the last five years including any accidents, facts, circumstances or allegations which may give rise to a claim:

What action has been taken to eliminate future accidents?

Has any similar insurance applied for or carried by the applicant been declined or cancelled by any insurer within the last three years?

Yes

If “Yes”, please provide full details.

Business risk assessment:

Business start date

No. of years of related prior experience

Please provide the best estimated values for the following: if n/a, then enter 0

a) Canada

Revenue

Payroll

# Of employees

b) US

Revenue

Payroll

# Of employees

c) Others

Revenue

Payroll

# Of employees

If “ Other ” please provide details:

Are company owners, executive officers or other office employees covered under worker’s compensation?

Yes

Please provide list of all operations performed and the breakdown for operation to the total revenue. (Use the + to add as many as needed)

Operation	%

Location of all of premises, operations, also indicate owner; Lessee; tenant. (Use the + to add as many as needed)

Operation performed	Location address including postal code	O/L/T

Total property value (Please include all office furniture, computers, laptops, equipments, etc.)

Other details for insurance purposes (if any)

Any additional relevant information you would like to share?

By submitting the above-mentioned information, the applicant declares that all statements made in the questionnaire and the information contained in documents submitted with it are true.

Submitting of this document does not bind the applicant to complete the insurance, but it is agreed that the questionnaire shall be the basis of the contract, should a policy be issued.

Business details:

Address

Contact person details:

Insurance details:

Business risk assessment:

a) Canada

b) US

c) Others

Finding exactly the right insurance coverage is not a daunting process at HIFA. We’ll make it straightforward and hassle-free so you’ll know exactly what you’re getting and can feel confident that you have the right coverage.