Company Name:
	Address:
	City:
	Province:
	Postal Code:
	Contact Person:
	Email Address :
	Phone Number:
	Present Insurer:
	Expiry Date:	/ / yyyy mm dd
	How long have you been in business:
	Loss/Claim history in last 5 years:
	Equipment Schedule:
	Year:	2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990
	Make:
	Type:
	Automatic CO2?	Yes     No
	Limit of Insurance:
	Commercial General Liability - Limit required	$1,000,000 $2,000,000
	Forest Fire Fighting Expenses - Limit required	$250,000 $500,000
		Disclaimer

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