Hole in One Claim Form & Terms and Conditions

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1 Hole in One Claim Form & Terms and Conditions Event Name: Date of Event: Participant Information: Name: Age Address: City Province Postal Code Phone Number: Course Name: Hole Number Yardage I, attest that on, I was successful in making a hole-in-one in accordance with the contest rules and regulations and the attached terms and conditions. I hereby declare that I do not fall into any of the following categories: Golf Professional - club or touring I hereby declare that: I am of the age of majority. I agree to the use of my name, photograph and potential appearance in any publicity associated with this contest, their affiliates, respective agents, and their respective promotional agencies without further compensation. Failure or disregard of any of the contest terms and conditions shall render the contract null and void and no prize shall be made. I further certify that the information is correct and that I have read agree to the rules and regulations of this contest. I fully understand that any misrepresentation of fact as to my eligibility, whether intentional or unintentional, shall be sufficient cause to forfeit any prize awarded by the contest sponsor. Dated this the day of, Year. Signed: Print Name: 901 6th Avenue Canmore Alberta T1W 2X5 Phone Fax

2 HOLE-IN-ONE WITNESS AFFIDAVIT Event Name: Date of Event: The following Witness(es) does hereby attest with his/her signature that he/she witnessed the HOLE-IN- ONE was achieved in totality, inclusive of witnessing the contestant taking the shot, the trajectory of the golf ball, and the ball going into the regulation hole, and also attests to the validity of this HOLE-IN-ONE claim. Further, said witness(es) does hereby accept all legal consequences, which may result if such claim is determined to be false or fraudulent. Attested - WIT NE SS No. 1 Attested - WIT NE SS No. 2 Attested W I T NE SS No. 3 Attested W I T NE SS No th Avenue Canmore Alberta T1W 2X5 Phone Fax

3 Terms and Conditions Elite Insurance Company must receive all applications for Hole-in-One insurance a minimum of three days prior to the tournament date/effective date of coverage. Elite Insurance Company must be notified, in writing, minimum one day prior to the tournament date of any requested changes to the policy. All change requests will be subject to underwriting approval. Failure to notify Elite Insurance may result in denial of coverage. In the event of tournament cancellation, Aviva Elite Insurance must be informed, in writing, a minimum of 24 hours in advance. Failure to notify Aviva Elite Insurance Company will result in the premium being fully earned. In the event of tournament postponement due to inclement weather, Elite Insurance Company must be notified, in writing, within 24 hours for coverage to be transferred to the make-up tournament date. Failure to notify Elite Insurance Company will result in the premium being fully earned. If the tournament cannot be rescheduled - see below. In the event of tournament cancellation due to inclement weather, Elite Insurance Company must be notified, in writing, by the golf course official as well as the broker, within 24 hours of cancellation for a full premium refund. Charges for signage, if applicable, will not be refunded. The minimum yardage on any insured hole must be 155 yards from tee to flagstick 1 for amateur players for prize values from $5,000 to $50,000. Yardage for prize values of $50,000 and higher will be at the discretion of the Aviva Elite. The insured hole must remain in its usual position with regard to tee box and flagstick placement for tournament play. The cup hole and pin placement cannot be positioned in a groove or valley on the green of the insured hole. All equipment used in tournament play must conform to RCGA standards. Equipment includes, but is not limited to, golf club(s), golf balls, flagstick, and cup hole. A participant is defined as any individual entered and playing in the insured tournament. Excluding course professionals or tour professionals. A participant (excluding companies, partnership or other business) having reached the age of majority in the province where they reside and who are eligible participants according to these rules. 1 For those tournaments booking Hole in One Insurance with Riverstone Insurance hole distance can be 155 yards for men and 145 for women.

4 The following participants are ineligible to qualify for or claim the contest prize: members of personnel, agents and representatives of Elite Insurance Company or its affiliates (defined as all of the companies affiliated with AVIVA Canada Inc.), its advertising or promotion agencies, and the suppliers of the prize, equipment and services related to this contest. If any participants are Professional golfers, Elite Insurance Company must be notified, in writing, a minimum of one day prior to the event for approval. Professional golfers or golf course professionals will be subject to a premium surcharge. Subject to prior Underwriting approval, Professional golfers or golf course professionals must play from a minimum of 175 yards from tee box to flagstick on the insured hole for prize values from $5,000 to $50,000. Yardage for prize values of $50,000 and higher will be at the discretion of the Aviva Elite. The insured tournament must be completed with groups made up of no less than three players per hole and no more than four players per hole. Each golfer is limited to one attempt at the hole-in-one. If an individual golfer is rounding out a group by teeing off twice, only the first drive is eligible for the hole-in-one. Tournament must have a minimum of 60 participants. 2 In order to qualify for a hole-in-one the ball must have remained in bounds at all times from tee box to cup hole. Mulligans are not eligible for hole-in-one claims. One independent tournament official must be present and monitoring play at each of the insured holes at all times during the insured event. Tournament official must be 18 years of age or older. Prize values of $50,000 and higher may require additional independent tournament officials to monitor the insured hole. The applicant must notify Elite Insurance Company of a potential hole-in-one claim within three business days of the insured event. The participant must complete the entire round of golf and complete the scorecard. This policy will respond once only per tournament per insured hole. Twenty percent (20%) prize restoration included with all Hole-in-One policies unless otherwise stated. 2 Booking your hole in one insurance with Riverstone Insurance exceptions can be made for smaller number of participants. Talk to a Riverstone golf specialist

5 Claims To report hole in one claims please call our toll free number To initiate the claim process for a hole-in-one the Insured must provide Elite Insurance Company with the complete contact information for all members of the foursome/threesome, and the contact information of the tournament official responsible for monitoring the insured hole. The tournament official(s) responsible for monitoring the insured hole must authenticate the scorecard of the participant who achieved the hole-in-one by signing on the scorecard that the hole-in-one was achieved and all the members of the foursome/threesome must also confirm the participant's successful hole-in-one on the insured hole by signing the scorecard. Upon receipt of all of the above information, Elite Insurance Company will supply the claimant with an affidavit and claim form. This must be completed fully and returned to Elite Insurance within five business days. Failure to provide a completed and signed claim affidavit within the specified time will result in the claim being denied. Failure to comply with all Terms & Conditions will result in a claim being denied. Signed authorization required from the Named Insured for direct cash payment to the winner of the designated prize value. 3 You can also notify Riverstone Insurance

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