PAL Insurance Canada Ltd.

Reference #

25-24741

Please confirm if the contents are personal: *

Personal Household Goods
Commercial Goods

Name of insured: *

Address: *

City: *

Province: *

Country: *

Postal Code: *

Phone Number: *

Email: *

Policy Effective Date: *

Months of coverage required: *

Personal Liability Limit: *

Are there ANY active forest fires within 50kms of the storage facility: *

Yes No

Facility Code: *

Unit Number: *

Unit Contents limit: *

Unit #2 Number:

Unit #2 Contents limit:

Unit #3 Number:

Unit #3 Contents limit:

Name of person completing this form: *

Mailing Address of person completing form: *

City: *

Province: *

Postal Code: *

Phone Number: *

Email: *

Verify Email: *

I /We hereby declare that the answers and declarations above, whether in my own hand or not, are true and that I /we warrant that no material fact has been withheld or misstated and agree that this proposal will form part of the policy and will form the basis of the contract with underwriters. I /we understand that the underwriters may declare any policy issued void in the event of any false statement, misrepresentation, omission or concealment whether made intentionally, innocently or accidentally. For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Lloyd's Underwriters' insurance business in Canada

I/we agree: *

Yes

I have reviewed the information above and have ensured it is 100% accurate. I have also included any Additional Insureds that may be required within the Venue’s rental agreement/requirements.

Check to confirm: *

Yes

How did you hear about us?:

If other, please specify:

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HELPFUL INFORMATION

CUSTOMER SERVICE

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Calgary, AB

Simcoe, ON

Montreal, QC