Facility User Program
SHORT FORM INSURANCE APPLICATION (NON-SPORT)
Name of Applicant / Insured:
*
Mailing Address:
*
Street Address
Street Address Line 2
City
Province / Territory
Postal Code
Contact Name:
*
First Name
Last Name
Describe Event / Activity:
*
Food / Drink Provided - by whom:
*
Location:
*
Effective Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Expiry Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Please provide the following information about daily activities and estimated attendance:
Rows
Main Activity
Attendance
Other
Total
Day 1
Day 2
Day 3
Will there be liquor served at any of the activities?
*
Yes
No
Describe any safety measures/risk management plans, i.e., parking, traffic, security, supervision, first aid, evacuation:
*
Signature:
Position:
*
Full Name:
*
First Name
Last Name
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: