Club Liability Application

This coverage is for INDIVIDUAL teams participating in an event that need to provide evidence of liabiltiy insurance to an event organizer for a one day or multi day event. If you have multiple teams each team must apply separately.

IT IS NOT FOR EVENT ORGANIZERS. EVENT ORGANIZERS MUST USE THE EVENT APPLICATION.

NAME OF TEAM*

NAME OF EVENT TEAM IS PARTICIPATING IN*

EVENT START DATE*

Date

IF MULTI DAY EVENT ENTER END DATE

Date

TEAM CAPTAIN/LEADER/CONTACT*

First NameLast Name

CONTACT MAILING ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

CONTACT PHONE NUMBER *

Area CodePhone Number

Water Class - SEE BELOW OF CLASS CATEGORY*

CLASS I-II $125CLASS III $145CLASS III-IV $160

CLASS CATEGORIES

CLASS I-II = FLAT RIVER, LAKE, INLETS NO RAPIDS

CLASS III = RIVERS, LAKES, INLETS - MODERATE FAST MOVING WATER WITH SOME RAPIDS UP TO LEVEL III

CLASS III-IV = OPEN OCEAN WITH IN-WATER CHANGES; RIVERS; OPEN LAKES, INLETS - ROUGH WATER WITH OCCASIONAL RAPIDS UP TO CLASS IV

Location of Event: (body of water, town, state)*

# team members*

NAMES OF ALL TEAM MEMBERS*

ENTER EACH NAME ON SEPARATE LINE

TEAM RPG MEMBER FEE*

$25 (Non Refundable)Current Paddlesport Risk Management Club Member. $0

ADDITIONAL INSUREDS REQUIRED - $20 PER ENTITY*

NOYES

# Additional Insureds*

Enter number of entities

Additional Ins Premium

ARE ENDORSEMENTS REQUIRED BY CONTRACT WITH A MUNICIPALITY, LANDOWNER, SPONSOR, PERMIT GRANTOR. DO NOT CHECK #'S 2-4 UNLESS YOU HAVE BEEN ASKED TO PROVIDE THESE BY THE CERTIFICATE HOLDER.*

GENERAL ADDITIONAL INSIRED CERTIFICATE OF INSURANCE30 Days Cancellation NoticeState or Municipality Endorsement CG 20-12Additional Insured Person/Organization CG 20-26Waiver of subrogationOther

Name and Address' of Additional Insureds (Please type each entity on separate line)*

I Certify that I all information is correct to the best of my knowledge and authorized to submit this application on behalf of all team members.

We agree to abide by the safety instructions of the event host/organizer and will complete the event hosts participant waiver.

Authorized Signee:

TOTAL DUE

COMMENTS/QUESTIONS

Payment - Please indicate payment method. If mailing - application will not be processed until check is received.*

Check by Email/ MailOnline

After you click submit you will be directed to make your payment. Applications submitted without payment when online method is chosen will not be processed. A copy of the application will be emailed to you.

Mailing address: PO Box 668, Kings Park, NY 11754.

Make Payable to Paddlesport Risk Management, LLC. Check must reach our office before the event.

Call with any questions: 631-321-6859

Email: paddlesports@jacka-liquori.com

TEAM EVENT APPLICATION