Palm Insurance Canada Inc.

Whistleblower Report

This Whistleblower Form allows the opportunity to disclose any incident/concern encountered in the workplace that violates any law, rule, regulation, corporate policy or involves any accounting or auditing concerns or irregularities or any behavior that potentially compromises the ethics, reputation, or integrity of Palm Canada.

Palm Canada is committed to taking every reasonable effort to ensure the identity of the individual reporting the incident/concern and the identity of the person who is the subject of the disclosure are kept confidential.

Please provide as much detail as possible. If you wish to remain anonymous, do not include your relationship to persons identified in your report.

Type of Incident/Issue:

Date of the Incident/Issue:

Duration of this incident/issue or how many times has this incident/issue taken place?

Please state the full names and titles of the person or persons engaged in the incident/issue.

Is there management involvement?

Yes No

Please provide details of this incident/issue. Please include specific and sufficient information to enable further investigation.

How did you become aware of this incident/issue?

Has management been made aware of this incident/issue?

Yes No

Would you be willing to arrange a meeting/phone call to discuss this incident/issue further?

Yes No

If so, would you be willing to provide your full name?

Your Title (optional)

Your Phone Number/Email Address (optional)