MBAIS - Insurance Service

1.

Has any owner/director or officer of the business, or the business itself sustained more than 3 losses, or had losses totalling more than $5,000 in the last three years for those sections to be covered by the policy?

* Yes No

2.	During the past five years:
	a. Has any owner/director or officer of the business ever been declared bankrupt or been involved with a business that has gone into receivership or liquidation?	* Yes No

	b. Has any owner/director or officer of the business, or the business itself been convicted of a criminal offence?	* Yes No

3.

Has the owner/director or officer of the business or the business itself had any insurance policy cancelled, declined or refused in the last 5 years?

* Yes No