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Establishment/Insured information
Name
Address
City
State
Country
Zip code
Phone number
Fax number
E-mail
Web Site
Contact information
Name
Title
Address information same as above
Address
City
State/Province
Country
Zip/Postal code
Phone number
Cell 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
Youth (8 - 17)
Adult (18 - 59)
Seniors (60 - plus)
Challenged/Disabled
Male
Female
Number of Participants
Number of Staff/
Committee Members
Number of Volunteers
Additionally Insured Certificate (1) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
More
Additionally Insured Certificate (2) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
More
Additionally Insured Certificate (3) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
More
Additionally Insured Certificate (4) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
More
Additionally Insured Certificate (5) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
More
Additionally Insured Certificate (6) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
More
Additionally Insured Certificate (7) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
More
Additionally Insured Certificate (8) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
More
Additionally Insured Certificate (9) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
More
Additionally Insured Certificate (10) :
Name (to appear
on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/
Municipalty
Sponsor
Sub-Contractor
Beneficiary/
Charity
Venue/Facility
Important
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.
I Agree
[U.S.] Triathlons Request
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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(bottom left) was not checked. If you do not agree your application request will not be processed.
N.B.
I Agree
(Waiver Requirement) was not checked. If you do not agree your application request will not be processed.
Event Information
Event Title:
Event Location, Venue Area:
City:
State:
Other Sites:
Event Type:
Triathlon
Duathlon
Expo
Dinner
Seminar
Camp
Event Distances:
Swim/Run
Bike
Run
Swim/Run
Bike
Run
Number of Years Event in Existence:
Number of Years of Experience of Event Director:
Event Course Information
Swim:
Pool
Lake
River
Bay
Ocean
Surf, Size Range
Name of Body of Water:
Number of Wave Starts:
Number per Wave Start:
Interval between Wave Starts:
, if more than one:
Course:
Point-to-Point
Out-and-Back
Triangular
Rectangular
Water Temperature Range:
Water Quality Control:
Number of Certified Lifeguards:
Number of Other Monitors:
Water Craft / # :
Kayaks /
PWC's /
IRB's /
Vessels /
Bike:
Road
Off-Road
Course:
Point-to-Point
Out-and-Back
Loop
Road Closures:
Closed
Open w/traffic
Coned w/traffic, Cone Spacing
Roadways:
Park Roads
City Streets
Country Roads
Dirt Roads
Traffic Control / # :
Police /
Certified Traffic Controllers /
Volunteers /
Course Monitors / # :
Draft Marshals /
Sag Vehicles /
Lead
Aid Stations / # :
Water Only /
Water and Other /
Water, Other & Medical /
Run:
Walkway
Road
Off-Road
Course:
Point-to-Point
Out-and-Back
Loop
Road Closures:
Closed
Open w/traffic
Coned w/traffic, Cone Spacing
Roadways:
Park Roads
City Streets
Country Roads
Dirt Roads
Traffic Control / # :
Police /
Certified Traffic Controllers /
Volunteers /
Course Monitors / # :
Lead
Volunteers /
Sag Vehicles /
Aid Stations / # :
Water Only /
Water and Other /
Water, Other & Medical /
Transition Area:
Open
Closed (fenced in)
Parking Lot
Grass Area
Other
Number of Racks:
Rack per:
Participant
Distance between Racks:
Age Group/Category Designations:
Yes
No
Monitors:
Yes
No
Number:
Swim/Bike/Run Crossover:
Yes
No
Seperate Entrances/Exits:
Swim In
Bike Out
Bike In
Run Out
Aid Stations / #:
Water Only /
Water and Other /
Water, Other & Medical /
Medical Assistance / # :
MD /
Nurse /
Paramedic /
EMT /
Athletic Trainer /
Other
Ambulance / #:
Advanced Life Support /
Basic Life Support /
Location of Ambulances:
Number of Medical Stations:
Location of Medical Stations:
Name of, and Distance to Nearest Hospital:
Defibulator (AED) on Site:
Yes
No
Type of Communications:
Walkie/Talkie
Nextel
Ham Radio
Cellular
Personel equipped:
Event Staff
Police
Medical
Water Safety
Aid Stations
Number of Devices:
Safety Plan:
Formal/Written
Informal/Non-written
Understood
Swim Caps Available:
Yes
No
Wetsuits:
Prohibited
Recommended
Required
Bike Mechanic On Site:
Yes
No
Bike Safety Checks:
Yes
No
Course Talks:
Yes
No
Course Information/Description:
Mailed
At Packet Pick Up
On-Line
Please provide, by
e-mail
(
e.g.
scanned attachments) or
fax
(514-394-1180), the following information:
Course Description and Maps. Include transition area.
Yes
No
Police Contact and Phone #:
Lifeguard Contact and Phone #:
Medical Contact and Phone #:
If you're ready, click 'Submit' to submit your completed application !
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