Your ticket information
The personal information provided on this form is collected under the authority of the Ontario Lottery and Gaming Corporation Act, 1999 and Regulation 198/00, s. 10 and 11. This information is intended to be used for the following principal purposes, and for any further purposes reasonably necessary to give effect to these purposes: (1) investigating and validating the prize claim; (2) sharing the information with third parties, including the Interprovincial Lottery Corporation, Alcohol and Gaming Commission of Ontario (AGCO), police services for such investigation and validation purposes and others; (3) monitoring and enforcing compliance with the Ontario Lottery and Gaming Corporation's (OLG) Lottery Prize Claim Policy and Procedures; (4) publishing the personal information of Claimants; (5) assisting OLG in managing its lottery games and in maintaining the integrity thereof; and (6) to comply with legal requirements. Where photocopies of certain identification (e.g., driver's licence) are required to be submitted to OLG for age and residency verification and/or for identification purposes, this information will be securely destroyed after verification takes place. By submitting this type of identification, you consent to the destruction thereafter. You may visit olg.ca, PlayOLG.ca or speak to a Player Support Representative for more information on the collection of this information and our Privacy Policy by calling toll free 1-855-978-PLAY (7529).
Date of Claim
Monday, September 23, 2019
Declaration
In consideration of and to induce OLG to deliver the prize, as referred to above, to me (the undersigned Claimant), I declare that:
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I belong to a group that purchased or played the Ticket.
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I am the only person having any right, interest or claim to the Ticket.
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I came into possession of the Ticket in a lawful and legitimate manner and in accordance with the rules and regulations governing the purchase and issuance of the Ticket.
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I purchased the Ticket in Ontario using my personal account on PlayOLG.ca.
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I am, or have been, within twelve (12) months prior to the date of this prize claim a person required to be registered under the
Gaming Control Act, 1992 (other than an iGaming vendor or iGaming entity as defined in the OLG Rules Respecting iGaming Lottery Games) that develops, supplies or maintains software, systems, products or services that relate to PlayOLG.ca ("Registrant"). Registrants include gaming-related suppliers, non-gaming related suppliers, trade unions, category 1 gaming assistants, and category 2 gaming assistants, in accordance with
Ontario Regulation 78/12.
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I am, or have been, within twelve (12) months prior to the date of this prize claim a director, officer, partner, sole proprietor or employee of a Registrant (as described above) and who is involved in the sale, redemption, distribution or manufacturing of lottery products, equipment or services that relate to PlayOLG.ca
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I am, or have been, within twelve (12) months prior to the date of this prize claim a person who is acting on behalf of a Registrant (as described above) and who is involved in the sale, redemption, distribution or manufacturing of lottery products, equipment or services that relate to PlayOLG.ca.
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I am, or have been, within twelve (12) months prior to the date of this prize claim
a partner of an iGaming vendor or iGaming entity.
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I am, or have been, within twelve (12) months prior to the date of this prize claim an individual directly on the payroll of:
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I am, or have been, within twelve (12) months prior to the date of this prize claim a director, officer or employee of:
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I am, or have been, within twelve (12) months prior to the date of this prize claim an individual consultant or public sector employee retained by OLG or the AGCO, through contracts of retainer for periods of thirty (30) calendar days or more in the aggregate
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I am, or have been, within twelve (12) months prior to the date of this prize claim an individual consultant retained by an iGaming vendor or an iGaming entity through contracts of retainer for periods of thirty (30) calendar days or more in the aggregate.
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I am, or have been, within twelve (12) months prior to the date of this prize claim a director, officer or employee of:
olgwindecform.(a)
the Interprovincial Lottery Corporation (ILC)
(b)
a Canadian provincial government lottery agency or corporation (other than OLG)
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I am, or have been, within twelve (12) months prior to the date of this prize claim
a member of the Ontario Provincial Police (OPP) assigned to the OPP's AGCO Investigation and Enforcement Bureau
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I am, or have been, within twelve (12) months prior to the date of this prize claim
a director, officer, partner, sole proprietor or employee of a supplier to OLG of independent audit, advisory or security services.
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I am, or have been, within twelve (12) months prior to the date of this prize claim
an employee of accountable Ontario Government Ministries of OLG or AGCO:
(b)
Ministry of the Attorney General
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I am, or have been, within twelve (12) months prior to the date of this prize claim
an immediate family member meaning a married spouse, common law spouse, child, parent or sibling of a person described in any questions 5 to 16 (whether living in the same residence or not) but excluding in-laws and step-family members
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I am, or have been, within twelve (12) months prior to the date of this prize claim
a relative (meaning a person other than an immediate family member) who is connected by blood or marriage and who resides with a person described in questions 5 to 16 above, and includes in-laws and step-family members
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This document shall be binding upon the heirs, executors, administrators and assigns of myself and shall enure to the benefit of OLG and ILC and their respective successors, assigns, affiliates, officers, directors, employees and agents.
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To the best of my knowledge, the information contained in this document is true and accurate.
Acknowledgements
For prizes of $1,000 or more and below $100,000, it is OLG's practice to publish the Claimant's name, place of residence, prize, game name, draw date and "Insider" status (if any) for a period of thirty (30) calendar days from the date of the prize payment on OLG's websites (OLG.ca and PlayOLG.ca). OLG also reserves the right to publish the Claimant's nickname (as used on PlayOLG.ca).
For prizes of $10,000 or more and below $100,000, if the Claimant has answered yes to question 5, 6, 7, 13 14, 15, 16, 17 or 18 above, it is OLG's practice to hold payment for thirty (30) calendar days after a tentative decision to pay the Claimant has been made, and during this time, publish the Claimant's name, place of residence, prize, game name, draw date and "Insider" status (if any) to allow any person(s) to dispute the Claimant's prize claim. OLG also reserves the right to publish the Claimant's nickname (as used on PlayOLG.ca).
And also in consideration of and to induce OLG to deliver the prize to me, I agree that I will not make a claim against OLG for broadcasting, printing, royalty or other rights and shall have no claim against OLG for any infringement of privacy rights, copyright, publicity rights or otherwise by reason of the publication or broadcasting of my name (including nickname), photograph, place of residence, prize, game name, draw date or "Insider" status (if any).
For prizes of $1,000 or more and below $100,000, it is OLG's practice to publish the Claimant's name, place of residence, prize, game name, draw date and "Insider" status (if any) for a period of thirty (30) calendar days from the date of the prize payment on OLG's websites (OLG.ca and PlayOLG.ca). OLG also reserves the right to publish the Claimant's nickname (as used on PlayOLG.ca).
For prizes of $10,000 or more and below $100,000, if the Claimant has answered yes to question 5, 6, 7, 13 14, 15, 16, 17 or 18 above, it is OLG's practice to hold payment for thirty (30) calendar days after a tentative decision to pay the Claimant has been made, and during this time, publish the Claimant's name, place of residence, prize, game name, draw date and "Insider" status (if any) to allow any person(s) to dispute the Claimant's prize claim. OLG also reserves the right to publish the Claimant's nickname (as used on PlayOLG.ca).
And also in consideration of and to induce OLG to deliver the prize to me, I agree that I will not make a claim against OLG for broadcasting, printing, royalty or other rights and shall have no claim against OLG for any infringement of privacy rights, copyright, publicity rights or otherwise by reason of the publication or broadcasting of my name (including nickname), photograph, place of residence, prize, game name, draw date or "Insider" status (if any).
For prizes of $100,000 or more, it is OLG's practice to publish the Claimant's name, place of residence, prize, game name, draw date, current photograph of the winner and "Insider" status (if any) for a period of thirty (30) calendar days from the date of the prize payment. OLG also reserves the right to publish the Claimant's nickname (as used on PlayOLG.ca).
If the Claimant has answered yes to question 5, 6, 7, 13, 14, 15, 16, 17 or 18 above, it is OLG's practice to hold payment for thirty (30) calendar days after a tentative decision to pay the Claimant has been made, and during this time, publish the Claimant's name, place of residence, prize, game name, draw date and "Insider" status (if any) to allow any person(s) to dispute the Claimant's prize claim. OLG also reserves the right to publish the Claimant's nickname (as used on PlayOLG.ca).
And also in consideration of and to induce OLG to deliver the prize to me, I agree that I will not make a claim against OLG for broadcasting, printing, royalty or other rights and shall have no claim against OLG for any infringement of privacy rights, copyright, publicity rights or otherwise by reason of the publication or broadcasting of my name (including nickname), photograph, place of residence, prize, game name, draw date or "Insider" status (if any).
I acknowledge and agree that I have read this iGaming Lottery Prize Claim Declaration Form and agree to be bound by its terms.
Completing and submitting this iGaming Lottery Prize Claim Declaration Form will initiate the prize payment process.
Your form has been submitted. A Prize Centre Representative may contact you by email or telephone if unable to credit your player's account within approximately one or two business day(s). For more information please visit PlayOLG.ca or call a Player Support Representative at 1-855-978-PLAY (7529).
Your form has been submitted. A Prize Centre Representative may contact you by email or telephone if unable to credit your player's account within approximately one or two business day(s). For more information please visit PlayOLG.ca or call a Player Support Representative at 1-855-978-PLAY (7529).
Your form has been submitted. A Prize Centre Representative will contact you for all claims of $100,000 or more to provide details of the prize payment process. Prize payment from $100,000 to $25 million are paid by cheque. Prize payment for more than $25 million are paid by wire transfer to your personal bank account. For more information please visit PlayOLG.ca or call a Player Support Representative at 1-855-978-PLAY (7529).
