Fire  All risks  Liability  Burglary 

   Products        Sprinkler Photos required

Agency:    Nº:    Policy nº:

Insured :    

Location Street:  

      City:   Postal code:    Telephone:

                                                                                        Contact:

 

                                                                      OCCUPANCY

By the insured:                                                                 Others:

                                                                                        COVERAGES

Fire insurance

Building:    $   Stock: $       Safe: $

 Fix. Equipement: $                             A.R.: $      

Our Proportion of the risk:     Risk covered:  YesNo  

Effective date of risk:   Date requested:  By:

Rapport in:   FrenchEnglish       
Recommendation in    FrenchEnglishBilingual    

 

                                                          SUBSCRIBER'S COMMENTS

                         Email  :                           

 Inssurance company: