My Site - H.E. Passingham Insurance Brokers Ltd.

Name:

Email Address:

Address:

City:

Province:

Postal Code:

Phone Number:

Age of Building:

Construction of building:

Is the building sprinklered:

Yes
No

How much area do you occupy:

Are you the only tenant:

YesNo

Is there a hydrant within 500 ft. (150 metres):

YesNo

Is there a fire hall within 3 miles (5 kms):

YesNo

Has insurance ever been denied or canceled:

YesNo

What type of business:

How many years in the business:

Have there been any insurance claims in the last 3 years:

What are the annual receipts:

What is the annual payroll:

Business Insurance