Slessor & Periard Insurance Limited

Name:
Email Address:
Address:
City:
Province:
Postal Code:
Phone Number:
Age of Building:
Construction of building:
Is the building sprinklered:	YesNo
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:

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