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Section 1

Reference #
12-60688


Name of insured/host: * 
   
Address: * 
   
City: * 
   
Province: * 
 
Postal Code: * 
   
Phone Number: * 
   
Email: * 
   
Additional Insured: * 
               

Section 2

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 the Event Venue or Event City/Municipality and provide their name and address. 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:    
   


Section 3

Type of Function: * 
 
Description Of Event: 
   
Number of People at Function: * 
   
Minors Allowed: * 
               
Policy period starts one hour before time shown on liquor permit and expires at the end of function.
Start Date: * 
 
Start Time: * 
 
# of days: * 
 

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 function commencement.

Section 5

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

Section 6

   

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: alberta@palcanada.com
Phone: 1-800-265-8098 ext: 221
Hours: Ontario 8:30am to 4:30pm EST Alberta 8:30am to 4:30pm MST

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