Please fill out this form to obtain your refund.

Any refund owed will be paid within 30 days following receipt.

IT IS RECOMMENDED THAT YOU KEEP A COMPLETED COPY OF THIS FORM FOR YOUR RECORDS. INTACT INSURANCE COMPANY RESERVES THE RIGHT, FOR A PERIOD OF ONE YEAR FROM THE DATE THIS NOTICE IS SENT, TO VIEW THE ORIGINAL OR TO DEMAND A COPY OF YOUR TRAIL PASS AND YOUR PINK INSURANCE CERTIFICATE FOR THE CIVIL LIABILITY COVERAGE PROVIDED BY INTACT INSURANCE.

Pursuant to section 441 of the Act respecting the distribution of financial products and services, I hereby rescind the following contract of insurance

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