Falkins Insurance
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Request a Quote for Commercial Insurance

Company Overview
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Company:
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Email:
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Phone:
 
Address (Street):
 
Address (Mailing):
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City:
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Province:
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Postal Code:
Primary Contact Information
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Primary Contact:
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Position:
 
Are you the decision maker for insurance?
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Phone:
 
Fax:
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Email:
Other Company Information
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Describe the operations of your organization:
(i.e. breakdown of revenue by source, etc.)
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# of Employees:
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Years in Business:
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Gross Revenue:
 
Any sales to US or other countries?
 
If yes, % of sales:
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Current Insurer (Broker/Company):
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Premiums:
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What do you need insured?
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List the amount of liability you need:
(Damage to property of others or injury to others)
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Other Coverage
List other coverages required such as Business Interruption, Boiler & Machinery, Crime, Motor Truck Cargo, Property of Others, etc.
(these are only a few of the coverages available)
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Claims / Losses
List all claims in the past 5 years:
 
What else should we know about you or your organization that would be important to placing insurance or to servicing you in the best way possible?

 

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