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Univesta,CabinetenassurancededommagesetServicesFinanciersInc.

3925,rueRachelEst,bureau100,Montréal(Québec)H1X3G8

Tél./Tel:1‐800‐267‐5377*514‐899‐5377–Télécopieur/Fax:514‐899‐5378–Courriel/e‐mail:optimiste@univesta.ca

OptimistInternationalCanada–Programmed’assurance/InsuranceProgram

Demandepourcertificatd’assurance/RequestforInsurancecertificate

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Nomduclub(incluantlenuméro)/NameofClub(includingnumber)

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Nomduclub/NameofClub:

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Membredemandantlecertificat/Memberrequestingcertificate:

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Adressepostale/Mailingaddress:

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Tél./Tel:()‐ Télécopieur/Fax*::()  ‐

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Courriel/E‐mail*:  *Obligatoire/Obligatory

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Nomdel’événement/Nameofevent:

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Encequiconcernel’événement,votreclubagit‐ilcomme/Withregardstothisevent,doesyourClubactas:

Commanditaire/Sponsor:

Oui/Yes Non/NoParticipant/Participant: Oui/Yes Non/No

Organisateur/Organizer:

Oui/Yes Non/No

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Lieudel’événement/Locationoftheevent:

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Datedel’événement/Dateoftheevent:

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L’entitéquirequiertunepreuved’assuranceresponsabilité/PartyrequestingproofofLiabilitycoverage:

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Nomdel’entité/NameofParty:

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Contact/Contact:

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Adressepostale/Mailingaddress:

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Télécopieur/Fax*:()‐Courriel/E‐mail*:*Obligatoire/Obligatory

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L’entitéexige‐t‐elled’êtredésignéecommeassuréadditionnel/IsthePartyrequestingtobenamedasanAdditionalInsured?

Oui/Yes Non/No

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L’événementimpliquet‐il/Doestheeventinvolve:

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1)Événementavecusagedebateaux,avionsouvéhicules/Eventswithuseofboats,aircraftsorvehicles:

Oui/Yes Non/No

2)Location,usageoupropriétédepiècespyrotechniques/Lease,useorownershipoffireworks: Oui/Yes Non/No

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