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APPLICATIONS
All-Star Events
Personal Information

Request Date     
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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.


[U.S.] All-Star Events Application

Please describe the sport activity (or event) to be insured: 
Describe auxiliary activities to be covered:
Please describe, in detail, any use of special effects, pyrotechnics, or use of mechanical devices, etc.:
Location of sporting activity:
Will you be erecting any bleachers?
Does any volunteer, owner, coach or official have a criminal record, or has ever had a criminal record?
Describe security protection:
Hold harmless
Emergency evacuation plan in place
Qualified medical personnel in attendance
Will alcoholic beverages be served?
Will alcoholic beverages be sold?
Will concessionaires provide you with certificates evidencing products liability with your organization as additional insured?
Do any of your events have over 5,000 spectators?
Will any other underlying coverage be provided?
Does the applicant now carry insurance of this type?
Has insurance coverage ever been cancelled or refused?
Have you ever filed for bankruptcy?
Do you have Accident Medical and Death & Disability Coverage?
Do you utilize a waiver & release?
Please describe any losses you have incurred over the past five (5) years, and provide insurance company loss runs:
Is there marketing material (flyer, brochure) that you can send us?
To receive information to help you plan your next fundraiser,
Click Yes.
Ticket Price No. of events
      If yes, please provide detail:
Type of construction Seating capacity
Number of Grandstands Type of Grandstands
      If yes, please explain:
What concessions will be sold?
Who contracts security?
Please specify the participant ages (youth means under 18 yrs of age):

Please enter the name of your previous insurer:
      If yes, please explain:
      If yes, please explain:
      If no, please explain:

Do you hold a valid liquor license?
Host liquor liability
Describe the method of ensuring patrons are over the age of 21:
Estimated liquor sales:


Type      Desired Coverage Limits ($)
General Liability
Participant Legal Liability
Medical
Other