QSAC TRACK SANCTION FORM

QSAC TRACK SANCTION FORM
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Which do you want to fill out?*

Statement Of ComplianceSanction/Insurance ApplicationClub Affiliation Application

Club Affiliation Application
Club Affiliation Application (where applicable)

The insurance coverage provided by QSAC is written to provide for all affiliated clubs under the master policy. The insurance carrier requires compliance with the following conditions in order to qualify as a QSAC Affiliated Club:

1. The Club must file with QSAC a completed form providing Club Name, Mailing Address and a list of Officers of the Club.

2. That each event organized by the affiliated club observe and enforce QSAC Safety Rules, Guidelines and Standards.

3. That each participant in each event be a QSAC member in good standing.

A Certificate of Insurance will be e-mailed to all clubs filing the appropriate forms and fees with the QSAC Secretary/Treasurer: Doreen Brown.

Sanctioned event applications should be routed through your QSAC Region or Area Director.

Note: The Certificate of Insurance provided at the time of club affiliation should be sufficient in most cases to satisfy the requirements of the site owner. You should provide the site owner or his representative a copy of your Certificate of Insurance. Only if the site owner requires a Certificate of Insurance specifically naming him as “Additional Insured” under the policy do you need to add his name as additional insured.
Club Name
Club Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
President's Name*

First NameLast Name
President's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
President's Phone*

Area CodePhone Number
Presidents Email*
example@example.com
President's QSAC #*
Vice President's Name*

First NameLast Name
Vice President's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vice President's Phone*

Area CodePhone Number
Vice Presidents Email*
example@example.com
Vice President's QSAC #*
Secretary Name*

First NameLast Name
Secretary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secretary Phone*

Area CodePhone Number
Secretary Email*
example@example.com
Secretary QSAC #*
Treasurer Name*

First NameLast Name
Treasurer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Treasurer Phone*

Area CodePhone Number
Treasurer Email*
example@example.com
Treasurer QSAC #*

Please fill out the following for payment. Your application can NOT be submited without payment online. If you would prefer to write a check you may PRINT the current application and mail it along with your check payment.
FEES*
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Annual Track Sanctioning Fee$50.00

Single Race Event Fee$30.00

Total $0.00
Payment Methods

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