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Section 1

Reference #
57-2502


Name of insured: * 
   
If individual, date of birth: 
 
Address: * 
   
City: * 
   
Province: * 
 
Postal Code: * 
   
Phone Number: * 
   
Email: 
   
Website: 
   

Section 2

Effective Date: * 
 
Start Time: * 
 
Expiry date: 
 
End Time: * 
 
Additional Insured: 
               

Section 3

Add Additional Insured: If an additional insured is required to be named, please describe the additional insured relationship to the event. Select if the additional insured is an Event Organizer, the Event Venue or Event City/Municipality and provide their name and address, the event name and address and the dates you will be exhibiting at the event. Then select the ADD ADDITIONAL INSURED. You may add more additional insureds by repeating these steps.
Type: * 
 
 
 
 
Name Of Additional Insured: * 
   
Address:    
   
City:    
   
Province: * 
 
Postal Code:    
   
With respect to the event:
Event name: * 
   
Event Address:    
   
Event City:    
   
Event Province: * 
 
Event Postal Code:    
   
Start Date: * 
 
End Date: * 
 


Section 4

Name of location of event: 
   
Address of location: 
   
City: 
   
Province: 
 
Postal Code: 
   
Estimated Attendees / Performance: * 
   
Estimated # of performances/ year: * 
   
Annual Receipts: * 
   
How many performers: * 
   
Limit of Liability (million): * 
 
Performer Type: * 
 
Additional Comments: 
   

Section 5

PAL's Performer program automatically includes up to $25 000.00 of property coverage. Please provide details below if value of your property is over $25,000,000.
What is the value of your property?: * 
 
 
 
Property value (if greater than $25,000): 
   
Property must be stored at a location with locked doors or a working alarm or 24 hour security while not in use. I / We agree: * 
        
Property items to be insured: * 
   
Property owned?: * 
               
Where will you store the property when not in use?: * 
   
Full property address: * 
   
Locked Doors: * 
               
Is the premise sprinklered: * 
               
Are there security personnel on site: * 
               
Is there 24 hour security: * 
               
Are there security cameras on site: * 
               
Is the premise alarmed: * 
                             
Are there additional security measures while NOT in use: 
   
Will the property to be insured be exposed to any special hazards? Please describe.: 
   

Section 6

Rental Reimbursement Limit: * 
 
Have we insured this risk previously? Please provide policy number: 
   
Have you been declined or cancelled by any other insurer(s).: * 
               
If so, please provide details: 
   
Loss History: 
   
General comments: 
   

Section 7

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: * 
        
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: * 
        
How did you hear about us?: 
 
If other, please specify: 
   
   

HELPFUL INFORMATION

Here are a few things to try to get your certificate successfully:
  1. Check the screen for any error messages. They will appear in red above the location of the error.
  2. Double check your information to make sure it has been entered correctly.
  3. You can always start over from scratch if you are having issues.
  4. You may want to try a different browser. Sometimes the settings of a certain browser may cause a problem and using a different browser will allow you to complete your submission.

 

CUSTOMER SERVICE

E-mail: ontario@palcanada.com
Phone: 1-800-265-8098
Hours: Ontario 8:30am to 4:30pm EST Alberta 8:30am to 4:30pm MST

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