Personal Information
Participants
Important
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I hereby warrant and confirm that the above information, to the best of my knowledge, is true and correct, and further certify that I have read all of the questions and answers of this application.
I understand this application is a requirement for coverage, a part of the contract and evidence of my acceptance of this insurance, and any falsification or misrepresentation will be deemed a breach of contract, voiding all insurance coverage.
It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or to SportsInsurance until accepted by the company or companies in writing.
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[U.S.] Athletic Officials Request
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Warning: Errors!!
The application was not submitted due to the fact that some
fields were missing or not filled in properly.
Please follow the  symbol and re-enter or review your answer.
Note: If the question for a required text input field is inapplicable, please indicate this, by for example,
entering 'N/A'.
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N.B. I Agree (bottom left) was not checked. If you do not agree your application request will not be processed.
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N.B. I Agree (Waiver Requirement) was not checked. If you do not agree your application request will not be processed.
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Request for additional coverage
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| Type |
Desired Coverage |
Limits ($) |
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General Liability
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Participant Legal Liability
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Medical
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Other
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If you're ready,
click 'Submit' to submit your completed application !
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The establishment/insured name is required
The establishment/insured address is required
The establishment/insured city is required
The establishment/insured State/Province is required
The establishment/insured Zip/Postal code is required
The establishment/insured Phone number is required
The establishment/insured e-mail is required
The establishment/insured e-mail is invalid
The contact's name is required
The contact's address is required
The contact's city is required
The contact's state/province is required
The contact's Zip/Postal code is required
The contact's Phone Number is required
The contact's e-mail is required
The contact's e-mail address is invalid
The policy's Effective date is required
The policy's Expiry date is required
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