Please enter the following  information and Cathy S. Ramsundar Insurance Broker will get back to you
to provide an analysis of your risks and the necessary insurance required to cover these risks

NOTE: USE TAB TO FOLLOW FIELD SEQUENCE

Contact Name
Business Name
Address Street
City	Province
Postal Code	Country
Work Phone	Cell Phone
E-mail	URL

Business Information:

Please describe your business

Does this business have any activities or sales outside Canada?	Please Choose Yes No
Does this business keep inventory on premises?	Please Choose Yes No

Does this business have machinery on premises?	Please Choose Yes No
Does this business own or lease motor vehicles for business?	Please Choose Yes - Own Yes - Lease Yes - Own and Lease No

Is this a Home-based business?	Please Choose Yes No
Does this business lease or own a building for business?	Please Choose Yes - Own Yes - Lease Yes - Own and Lease No

Does this business have more than 1 location?

Please Choose Yes No

Are you looking to insure more than 1 location?

Please Choose Only this one More than 1

Group Benefits Information

How many employees work at this business?

Please Choose 1 - Only me 1-10 11-20 More than 20

Does this business have a Group Benefits Plan for Employees?	Please Choose Yes No
If No! Do you want a Group Benefits Plan for your employees?	Please Choose Yes No

Insurance Information:

How long has the business been insured with the current insurance company?

Please choose Not insured/Less than 1 year More than 1 and less than 2 More than 2 and less than 3 More than 3 and less than 4 More than 4 and less than 5 More than 5 and less than 6 More than 6 and less than 7 More than 7 and less than 8 More than 8 and less than 9 9 or more years

What is the expiry date of your current business insurance policy?

Month January February March April May June July August September October November December Year 2010 2009 2008

When would you like the new insurance coverage to begin?

Month January February March April May June July August September October November December Year 2010 2009 2008