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Contact Information

Jennifer Stackhouse

1-800-265-8098 ext: 242

My regular office hours are Monday- Friday, 8:30 am to 4:30 pm Eastern Time

Are you a Broker or Agent?   

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Section 1

Reference #

Location Province: * 
Distance: * 
Prize value: * 
Number of Participants per game: * 
* only 1 attempt per participant allowed
Number of games: * 

Section 2

If you wish to bind coverage, please complete the application below:
Any Professional Players?: * 
Name of insured: * 
Address: * 
City: * 
Province: * 
Postal Code: * 
Phone Number: * 
Email: * 

Section 3

Tournament Name: * 
Are all participants randomly selected?: * 
Game #1 Date: * 
Game #2 Date: 
Game #3 Date: 
Game #4 Date: 
Game #5 Date: 
Game #6 Date: 
Game #7 Date: 
Game #8 Date: 
Game #9 Date: 
Game #10 Date: 
Game #11 Date: 
Game #12 Date: 
Game #13 Date: 
Game #14 Date: 
Game #15 Date: 
Game #16 Date: 
Game #17 Date: 
Game #18 Date: 
Game #19 Date: 
Game #20 Date: 
Game #21 Date: 
Game #22 Date: 
Game #23 Date: 
Game #24 Date: 
Game #25 Date: 
Location Name: * 
Location Address: * 
City: * 
Postal Code: * 
Do you have loss history within the last 5 years?: * 
I have read and agree to the above terms and conditions: * 

Section 4

Name of person completing this form: * 
Mailing Address of person completing form: * 
City: * 
Province: * 
Postal Code: * 
Phone Number: * 
Email: * 
Verify Email: * 
Application and full payment must be submitted at least 1 hour (minimum) prior to the tournament/contest start time.
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: 


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Phone: 1-800-265-8098
Hours: Ontario 8:30am to 4:30pm EST Alberta 8:30am to 4:30pm MST

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