Notice of Rescission of an Insurance Contract

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.

Additional information:

An Act respecting the distribution of financial products and services, (chapter D-9.2).

Your refund calculation.

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

* All fields are mandatory

Effective date and contract information FCMQ

* Effective date of the contract FCMQ

Place of signature of contract

Trail pass

* Select your type of trail pass

* Policy no./Trail pass no.

* Transaction number

* Club number

Insured vehicle

* Snowmobile make

* Snowmobile model

* Snowmobile serial no. 17 characters

* Snowmobile registration no. Example: V99999X

* Your acknowledgment

* Policy number of the insurance covering the snowmobile (liability)

* Insurance company covering the snowmobile (liability)

Insured person's information

* Last Name Name of person to send check to

* First Name

* Address Address of the person to send the check to

Apartment number, condo number, PO Box etc.

* Municipality

* Province/State

* Country Canada United States Other

* Postal Code/ ZIP code

* E-mail address

* Please confirm your E-mail Address

Type the characters

Notice of Rescission of an Insurance Contract

Q.P.F. No. 1 – Owners’ Form
– Coverage for Civil Liability – Underwritten by Intact Insurance

Please fill out this form to obtain your refund.

Additional information:

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

© 2021 Copyright. All rights reserved | Intact Insurance.

Notice of Rescission of an Insurance Contract

Q.P.F. No. 1 – Owners’ Form– Coverage for Civil Liability – Underwritten by Intact Insurance

Please fill out this form to obtain your refund.

Additional information:

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

© 2021 Copyright. All rights reserved | Intact Insurance.

Q.P.F. No. 1 – Owners’ Form
– Coverage for Civil Liability – Underwritten by Intact Insurance