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Bay Adelaide Centre, West Tower Suite #850, 333 Bay Street Toronto, ON M5H 2R2 P: 416.774.2477 F: 416.497.7581 www.burnsandwilcox.caDisability Insurance Declaration To be completed by the proposed

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Burns & Wilcox Canada is a leading wholesale insurance brokerage and underwriting firm that specializes in providing a variety of insurance products to clients in Canada.

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