COMMERCIAL RENEWAL APPLICATION

Broker: Policy#: Expiry Date of Renewal:

Named Insured:

Change in name? If so, describe in full:

Mailing address:

BUILDING INFORMATION: Year built: # of Stories: Sq Footage:

CONSTRUCTION:Frame Masonry Non-Combustible Fire Resistive Other (Describe):

FOUNDATION:Concrete/Poured Concrete Brick Stone Post & Pier Preservative/Treated Lumber Other (Describe):

HEATING: Natural gas furnace Hot water boiler Oil furnace* Electric Woodstove* Other (Describe):

*please attach Questionnaire/Photos

WIRING: Fuses Circuit Breakers 60 amp 100 amp 200 amp Aluminum Wiring Knob & Tube wiring

PLUMBING: Copper: %PVC: %Galvanized: % Other: % Describe:

UPDATE INFO: Heating: Electrical: Plumbing: Roof:

FIRE PROTECTION: Fire hydrant: Within 300m? Yes No Firehall:Within 5m/8km? Yes No Volunteer Paid

PRIVATE PROTECTION: Fire Extinguishers? Yes No Smoke Detectors? Yes No Monitored Alarm? Yes No

Any Change in property values? Yes No

Description of operations:

# years in operation: Changes in operation? Yes No If so, describe in full:

Annual Sales / Expiring Term / Next Term
Canada
U.S.A.
Foreign (Specify Countries)

No. of Employees: Gross Annual Payroll : $

Cost of Work Sublet : $

Coverage: As per expiring policy or Specify:

Limit of Liability: As per expiring policy or Specify:

Describe all losses paid or reserved that occurred or were reported during the past five years:

DECLARATION

I/We declare and warrant that after enquiry all statements and particulars contained in this Proposal and addenda are true and that no information whatsoever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this Proposal and should the above particulars alter in any way I/We will advise Underwriters as soon as practicable. I/We understand that failure to disclose any material facts that would be likely to influence the acceptance and assessment of the Proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect. I/We hereby agree and accept that this Declaration shall be the basis of the contract between both parties if entered into. I/We have been advised by the broker and consent to any information that may be perceived as personal information for collection, appropriate use, and disclosure of to third parties. Protection and Electronic Documents Act (PIPEDA)

(Print Name of Proposed Insured)

Signature of Insured & TitleDate

#100 1400 1st Street SW
Calgary, AB T2R 0V8
Tel.: 1-855-745-1010
Fax: (403) 237-9976
/ 4405, boulevard Lapinière (head office)
Brossard, QC J4Z 3T5
Tel.: 1-855-745-1010
Fax: (450) 672-5533 / 2550, boulevard Daniel-Johnson, #420
Laval, Québec H7T 2L1
Tel.: 1-855-745-1010
Fax: 450-681-7313
/ 235 Yorkland Blvd., Suite 1100
Toronto, Ontario M2J 4Y8
Tel.: 1-855-745-1010
Fax: (416) 925-7260