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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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[U.S.] Sports Application
Request Date 01/28/2012 10:32:14 AM
| If yes, please describe, in detail, any use of special effects, pyrotechnics, or use of mechanical devices, etc.:
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| If yes, please explain:
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| If yes, please describe any losses you have incurred over the past five (5) years, and provide insurance company loss runs:
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| If yes, please explain:
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| If insurance has been declined or cancelled, please explain:
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Please note that eligibility for insurance coverage under this programme
requires that the applicant
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utilize the client waiver
available here (to download, right click and select 'Save Target').
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| Individuals Covered |
| All players, managers or coaches of the Policy holder |
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| Activities Covered |
| While participating as a member of the team in a scheduled game,
an official tournament game, or in a practice session of the team;
or travelling directly to or from a game or practice session as a member of the team
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| Rates Contemplate |
| All policies are subject to minimum premiums
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| All standard terms, conditions and exclusions apply
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| Coverage cannot be back dated
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| Coverage Limits |
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General Liability: |
$1,000,000 Per Occurrence / $2,000,000 Aggregate |
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Accident Medical: |
$5,000 AD&D / $25,000 (or as selected) Acc Med Benefit |
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Optional Liability Coverages (Additional Premium Will Apply)
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| Please select desired optional coverage(s).
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| Abuse/Molestation Coverage
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This endorsement covers the defense of the accusation against a staff member.
Per Occurrence/Aggregate Coverage for claims of Abuse/Molestation can be added for an additional premium of:
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$50,000/$100,000 Abuse/Molestation |
$1,250.00* |
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$100,000/$500,000 Abuse/Molestation |
$1,875.00* |
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$500,000/$1,000,000 Abuse/Molestation |
$2,500.00* |
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$1,000,000/$1,000,000 Abuse/Molestation |
$2,815.00* |
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Abuse/Molestation Coverage NOT REQUIRED |
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*Fully Earned at Policy Inception. Additional Premium amount may be more, depending on number of participants.
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| Hired/Non Owned Auto Liability Coverage
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$1,000,000 Hired/Non Owned Auto Liability Coverage can be added for an additional
premium/taxes/fees of:
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$1,110.00 (fully earned at inception. May be more, depending on cost of hire.) |
If Hired/Non Owned Auto Liability Coverage is Required, please complete the
'Hired/Non Owned Auto Liability Coverage Section', below.
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Hired/Non Owned Auto Liability Coverage NOT REQUIRED |
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| Excess Liability Coverage
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Follow-Form Excess Liability Coverage can be added for the following limits
and premiums/taxes/fees:
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$1,000,000/$1,000,000 Excess Liability |
$1,110.00* (Total Liability Coverage Amount $2M/$3M) |
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$2,000,000/$2,000,000 Excess Liability |
$2,210.00* (Total Liability Coverage Amount $3M/$4M) |
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$3,000,000/$3,000,000 Excess Liability |
$3,310.00* (Total Liability Coverage Amount $4M/$5M) |
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$4,000,000/$4,000,000 Excess Liability |
$4,410.00* (Total Liability Coverage Amount $5M/$6M) |
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$5,000,000/$5,000,000 Excess Liability |
$5,510.00* (Total Liability Coverage Amount $6M/$7M) |
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Excess Liability Coverage NOT REQUIRED |
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*Fully Earned at Policy Inception. Additional Premium amount may be more, depending on coverage period.
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Hired/Non Owned Auto Liability Coverage Section
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If you're ready,
click 'Submit' to submit your completed application !
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