October 20, 2017
Vegreville Insurance Ltd

Business Quote

General Information
Contact Name *
Email *

Business Name
Address
City
Postal Code
Business Phone
Fax
Current Insurance Company
(not agency)
Company Name
Policy Expiration Date
Current Insurance Coverages
Current Coverages Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Professional Liability
Other
Business Information
How long in Business? (yrs)
Please give a brief description of your business and clientele
Property/Premises Information
Address
Occupancy Status Owner  Tenant
Year Built
% Occupied
Sprinklers Yes  No
Construction Type
Stories
Sq. Footage
Estimated Rebuild Cost
Contents
Other Property (specify)
Insurance Information
Other
Annual Gross Sales: (before taxes)
Liability Limit Requested $1,000,000
$2,000,000
$5,000,000
Describe any claims you've had in the past 5 years
Additional Comments
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.