Club ApplicationRegatta/Festival applicationAdditional Insured Certificate RequestHull and Equipment ChangesClaim Forms


Application for Clubs

General Information

Name of Organization:
Address:
City State Zip
Contact: Title
Tel# Fax# Email
Desired Effective Date Quote needed by

Liability Section:
1. Number of Members/Students:
(All Members and Students must sign a Release or Waiver of Liability to be eligible for this insurance. Please attach a copy of your Form in step 2 of the application process.)

2. Jones Act coverage is available at $125 per coach. If desired, on average how many paid coaches are on the water at any one time?

3. Do you rent boats? Yes No
(If you rent boats to Members or the public) Gross Receipts $

4. Do you borrow boats? Yes No
If yes, what is the aggregate value of the borrowed boats $ How Often?

5. Do you run or host regattas? Yes No
How Many?

6. Season (Club is open for rowing- dates):


Supplemental Coverages (please complete if coverage is desired)
1. Do you rent your storage rack space? Yes No
If yes, Please complete Marina Operators Legal Liability Application
2. Do you own docks? Yes No
If yes, please complete The Dock Coverage Application
3. Owned Boathouse? Yes No
If yes, please complete Application for Building Coverage


Owned Watercraft

Hull and Equipment: Please attach a Schedule of vessels in Excel Format and equipment including:
Builder, Year, Model, Hull ID Number, Current Value in step 2 of this application.

Loss History

LOSS HISTORY Do not leave blank, if there have been no claims please state that:
YEAR PAID LOSSES OUTSTANDING LOSSES
20
20
20
20
20

USE ADDITIONAL SPACE TO DETAILS MAJOR LOSSES, UNUSUAL LOSSES, AND RECOVERIES.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.


Printed Name

Signature

Title

Date




Step 1 of 2