Application for Clubs

Note: This form is a 3 step process. Please complete the Application Form, then the Terrorism Form (step 2). In step 3 you will be able to upload your Hull and Equipment document/excel files. This will complete your application process. Thank you.

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 3 of the application process.)

2. For Jones Act Coverage, what are the average number of coaches and launch operators on the water:

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 3 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 3