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1-800-265-8098 ext. 828

ontario@palcanada.com



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Section 1

Reference #
21-36446


Select Policy Document Language: * 
 
Province: * 
 
Event Location - Name of Venue: * 
   
Name of location of event: * 
   
Address of location: * 
   
City: * 
   
Postal Code: 
   
Location Type: * 
 
Limit of liability required: * 
 
This is private property: * 
               

Section 2

Name of insured: * 
   
If individual, date of birth: 
 
Address: * 
   
City: * 
   
Province: * 
 
Postal Code: * 
   
Phone Number: * 
   
Email: * 
   
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 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 4

Event Type: * 
 
Event Details: 
   
Event Effective Date: * 
 
Start Time: * 
 
Event Expiry Date: * 
 
End Time: * 
 
Max # of attendees (per day): * 
   
Max # of attendees (whole event): * 
   
Admission Fee ($): * 
   

Section 5

Will there be music at the event?: * 
 
 
 
 
Name of performer(s): 
   
Music Type: 
               
Music Genre: 
   
Will there be vendors or exhibitors at the event: * 
               
Is proof of insurance a requirement for the vendors/exhibitors to set-up at the event: 
               
Will food and beverages be served at the event: * 
               
Who is providing food and / or beverages?: 
 
Will there be alcohol served/consumed at any of the activies: * 
               

Section 6

Who is in charge of the service of alcohol: 
 


All Rules and Regulations pertaining to the service and/or consumption of alcohol must be abided.

Activity #1 where alcohol will be served/ consumed
Date: 
 
From: 
 
To: 
 
Location: 
   
# of patrons: 
   
Are servers trained: 
               
Activity #2 where alcohol will be served/ consumed
Date: 
 
From: 
 
To: 
 
Location: 
   
# of patrons: 
   
Are servers trained: 
               
Activity #3 where alcohol will be served/ consumed
Date: 
 
From: 
 
To: 
 
Location: 
   
# of patrons: 
   
Are servers trained: 
               
Activity #4 where alcohol will be served/ consumed
Date: 
 
From: 
 
To: 
 
Location: 
   
# of patrons: 
   
Are servers trained: 
               
If alcohol is served/ consumed at additional activities, please insert information in comment box below.
Additional details/ activities: 
   

Section 7

Will fireworks/ special effects or petting zoos/ other animals be involved in the event. If yes, a certificate of insurance or further underwriting may be required.* 
 
Will there be a parade: * 
               
If yes, please specify the number of units in the parade: 
   
Length of Parade: 
   
Police Escort: 
               
Are there any horses: 
               
If YES to horses, please confirm if each horse owner is required to provide proof of insurance prior to the parade.: 
               
Is the applicant providing any overnight camping or other accommodation: * 
               
Accommodation type: 
 
Other - please specify: 
   
If event involves youth, please provide sleeping arrangement details: 
   
Will there be any inflatables/ jumping castle: * 
               
If yes, is coverage secured elsewhere?: 
               
If no coverage is in place elsewhere, an extension with a sublimit of $250,000.00 is available to be added to the policy, subject to additional premium of $50.00.
Do you want coverage?: 
               
Will any temporary grandstands, bleachers or stages be set-up: * 
               
If yes, Who will do the installation: 
   
Will a certificate of insurance be provided by the installers: 
               
Please provide details on the installation: 
   
Who will be providing security at the event: * 
 
How many people on site for security/ supervision: 
   
Will there be any designated children areas (ie: babysitting): * 
               
If yes, please provide pick-up / identification procedures: 
   
Has the event been held in the past: * 
               
Have you been declined or cancelled by any other insurer(s).: * 
               
If so, please provide details: 
   
Previous Insurer and premium paid: 
   
Loss History: 
   
Do you have any special request for coverage: 
   
Do you require property coverage for items your own or rent?: 
 
Property covered, other amount: 
   
Please describe the property to be covered?: 
   
General comments: 
   
You may wish to attach any photos, posters, brochures, diagrams, or any additional information that would be may be useful for underwriting purposes.
Attachment: 
   
Attachment #2: 
   

Section 8

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: 
   


Please note that this is an application only. It does not constitute an insurance policy. Insurance shall become effective only on issuance of a policy or written binder specifically authorized by the company or agency. Quotations will be based upon the information provided and applicant warrants information provided.

   

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 ext. 828
Hours: Ontario 8:30am to 4:30pm EST Alberta 8:30am to 4:30pm MST

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