Club Liability Application

To access this Club Liability program your club MUST be a member of one of the USDBF affiliates - ERDBA, ADBA, PDBA OR SRDBA.

If you are not a member or need to renew your membership please click the applicable affiliate link above to complete the 2025 membership process BEFORE you complete this application.

PREMIUM AND FEES ARE FULLY EARNED: NO REFUNDS FOR MID TERM CANCELLATION

IF YOU APPLY FOR COVERAGE AND ARE NOT A MEMBER OF ONE OF THE REGIONAL AFFILIATES ABOVE YOUR COVERAGE WILL BE CANCELLED AND NO PREMIUM WILL BE REFUNDED. COVERAGE CAN BE REINSTATED ONCE YOU PROVIDE PROOF OF A REGIONAL MEMBERSHIP.

CLUB IS*

New to Insurance ProgramRenewing Coverage

Please indicate the USDBF affiliate which your club is a member of?*

PDBAERDBAADBASRDBANON of above - please contact the applicable affiliate using link above. You can then close the affiliate tab and continue to complete this application.

NAME OF CLUB/ASSOCIATION/ORGANIZATION*

CLUB MAILING ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

INSURANCE CONTACT NAME*

First NameLast Name

CONTACT EMAIL *

example@example.com

CONTACT PHONE NUMBER *

Area CodePhone Number

DOES CLUB OWN: (FOR NEW CLUBS ONLY)

BoatsDockClubhouseother

DOES CLUB LEASE/BORROW/RENT BOATS? (FOR NEW CLUBS ONLY)

WHAT IS YOUR 'PADDLING' SEASON? - Indicate months or year round.*

HOW MANY TOTAL MEMBERS IN THE CLUB/ORGANIZATION?*

DOES YOUR CLUB MAINTAIN DIRECTORS & OFFICERS LIABILITY?

NAME OF RIVER, LAKE, OCEAN, BAY WHERE YOUR CLUB OPERATES FROM? *

Please clearly identify lake, river, ocean, bay paddled in

ADDRESS OF PHYSICAL LOCATION OF CLUB/TRAINING (If different from mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PREMIUM CALCULATION

Premium is based on your clubs active paddling members and annual paddling schedule.

ENTER IN SECTIONS A, B & C - SECTIONS WILL AUTO CALCULATE

A) Enter the number of total ACTIVE PADDLING club members (including officers, directors, steerers, drummers, coaches)*

B) How many days of week does club have practices?*

C) How many months during the year does the club paddle (eg March-Oct = 8 mths)*

This is total number of paddle days for your club

CHECK THE TIER BASED ON THE NUMBER OF PADDLE DAYS ABOVE*

1-5,000 Paddle Days $4305,001 - 10,000 Paddle Days $80610,001+ (unlimited) Paddle Days $1,212

Program Admin Fee*

$100 (Non Refundable)

DO YOU NEED TO ADD ADDITIONAL INSUREDS*

YESNO

IF YOU HAVE MORE THAN 10 ADDITIONAL INSUREDS PLEASE ENTER 10 INTO THE BOX AND UPLOAD OR EMAIL A LIST WITH NAMES AND ADDRESS OF ENTITIES. SEPARATE ENDORSEMENTS FOR WAIVER OF SUBROGATION AND PRIMARY NON-CONTRIBUTORY ARE NO LONGER ISSUED AS THEY HAVE BEEN INCLUDED IN THE POLICY TERMS AND CONDITIONS. YOU WILL RECEIVE AN ADDITIONAL INSURED CERTIFICATE WITH THE APPLICABLE FORM NUMBERS ALONG WITH COPIES OF THE FORMS TO DISTRIBUTE TO THE CERTIFICATE HOLDER.

IF YOU HAVE NOT BEEN ASKED TO PROVIDE ENDORSEMENTS CHECK THE "ADDITIONAL CERTIFICATE OF INSURANCE" BOX ONLY.

Please Note: Endorsements must be issued by the insurance carrier and take up to up to 10 business days during peak season to issue. Certificates are issued by our office and issued with your insurance documents.

If more than 6 are required enter 6 below and use the Additional Insured Request Form on our website www.paddlesportriskmanagement.com . DO NOT EMAIL US FOR ADDITIONAL INSUREDS A FORM MUST BE COMPLETED.

Please make sure the address is correct. Certificates will not be issued without an address. Please do not state "same as last year".

# Additional Insureds $20 PER ENTITY*

Enter number of entities

Subtotal - additional insureds

Additional Insured Endorsements - check all that apply DO NOT REQUEST IF THE ENTITY HAS NOT ASKED YOU TO PROVIDE AN ENDORSEMENT. ENDORSEMENTS CAN TAKE UP TO 14 BUSINESS DAYS TO RECEIVED FROM INSURANCE COMPANY

1) Addtional Insured Certificate2) CG2012 State or Government Agency Endorsement3) CG 2026 - Designated Person or Organization4) 30 days prior notice of cancellation5) Waiver of Subrogation6) Primary Non ContributoryOther

Additional Insured

Upload requirements/contract or agreement of any entity requesting endorsements

Browse Files

DIGITAL WAIVERS:

An digital waiver system is available for clubs to access. Your club name and/or logo will be added to the waiver. It is recommended to provide a generic email address for notifications that a waiver has been signed to go to. You will not be required to mail or email copies of club waivers as our office will download at the end of the season. You will be given a link to post to your websites/social media pages or to email to members and guests in additional to a QR code. You will have access to a back office where you will see all signed waivers.

If you are renewing access to the system once the club application is processed the waiver will auto update.

SELECT WAIVER OPTION*

PDF WAIVERNEW DIGITAL WAIVER SYSTEM $35 SETUP AND DATA STORAGERENEWING WAIVER SYSTEM $35WE USE AN ALTERNATIVE E-WAIVER SYSTEM

Club Email Address for Waiver signing notifications will go

IT IS RECOMMENDED YOU USE A GENERIC EMAIL ADDRESS

If you would like us to insert your club logo to the waiver please upload a file of the logo. If you have previously provided it you do not need to upload again.

Browse Files

(pdf; gif, png, jpg, jpeg formats)

Acceptance of this proposal confirms your desire to obtain insurance through the Sports, Liesure, & Entertainment Risk Purchasing Group. I hereby certify that the USDBF Safety Requirements have been met and will be adhered to as well as the US Coast Guard or state laws, whichever is stricter, during regular club activities. I further understand that all PFD's used are USCoast Guard class I, II,III or V approved and that all members and guests will sign the approved USDBF release of liability waiver copies of which will be sent to the USDBF administrator annually.

USDBF Safety Addendum - PLEASE READ or DOWNLOAD

The undersigned accepts, on behalf of the club/organization/team, the terms & conditions of USDBF Insurance Program and Safety Addendum and agrees to comply with all requirements.*

First NameLast Name

Signature*

Date Signed*

Time*

:HourMinutesAM/PM Option

TOTAL PREMIUM DUE

AUTO CALCULATE

READ BEFORE SUBMITTING

After you click submit you will be directed to make your payment via EPayPolicy. Applications submitted without payment will not be processed.

If you would like to mail a physical check please check the box below. Do not click the PayNow Button after submitting:

Select payment method - PLEASE NOTE: If mailing a check your application will not be processed or any certificates issued until the premium is received in our office -WE DO NOT ISSUE INVOICES FOR PREMIUM AFTER APPLICATION IS SUBMITTED*

Mail Premium CheckOnline (No vendor processing fee for check payment. Vendor fee assessed for credit/debit card)

COMMENT

LEAVE A COMMENT OR SUGGESTION TO HELP US IMPROVE OUR SERVICES

Make check payable and mail to:

Paddlesport Risk Management, LLC -

PO Box 668

Kings Park, NY 11754

IF YOU LIKE OUR SERVICES PLEASE LEAVE A REVIEW ON GOOGLE REVIEWS, YELP OR ON ANY SOCIAL MEDIA PLATFORM. WE THANK YOU FOR YOUR SUPPORT OF THE USDBF PROGRAM.

Have questions contact Maria Liquori

PO Box 668, Kings Park, NY 11754

Phone (631) 321-6859

Email: paddlesports@jacka-liquori.com

2025 ANNUAL CLUB LIABILITY APPLICATION