Personal Information

Request Date
Start Here
Establishment/Insured information
Name
Name of owner(s)
Address
City
State
Country
Zip code
Phone number
Fax number
E-mail
Web Site
Contact information
Name
Address information same as above
Address
City
State/Province
Country
Zip/Postal code
Phone number
Fax number
E-mail
Agent/Broker information (if applicable)
Name
Phone number
Fax number
E-mail
Desired coverage dates
Desired effective
Desired expiry

Participants

	total	females	males
age 9 and under
age 10 to 12
age 13 to 15
age 16 to 18
Adults (19+)

Total player participants
Total non-player participants
Estimated number of spectators
Total volunteers
Total directors
Total referees
Other participants
Number of teams
Estimated total non-membership receipts

Additional Named Insured

Name	Address	Role

Applicant for this insurance is a: Team League Tournament Camp Other (specify):

Important notice

It is understood and agreed that the insurance coverage will not apply from injuries resulting from intentional body checking or boarding, violating the rules and by-laws of the association, league or team.

It is understood and agreed that the coverage does not apply to bodily injury to a participant unless you implement sufficient procedures to secure from each participant and deliver to us simultaneously with notice of a participant claim a valid release and waiver of liability and indemnity agreement form as attached and made part of the policy dated and signed by the participant prior to the time of the occurence in which the participant was injured.

It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or to the company until accepted by the company or companies underwriting this application.

I Agree