Club Liability Application

This annual coverage is for clubs; associations and organizations and their members for general activities on and off water. It includes, but is not limited to, training, practices, coaching, club/association cruises, meetings, banquets, small fundraisers, recruiting, demonstrations, club/association social events. This is NOT for racing events or special events where members of the public are paying to participate in a race, cruise or demonstration. To access this program your club or association must be a member of Paddlesport Risk Management, LLC. Annual membership is $25 and payable with premium. PLEASE NOTE: ALL PREMIUM ON ANNUAL CLUB INSURANCE IS FULLY EARNED AND NON-REFUNDABLE.

NAME OF CLUB/ASSOCIATION/ORGANIZATION

CLUB MAILING ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

CONTACT NAME *

First Name Last Name

CONTACT EMAIL *

Confirmation Email example@example.com

CONTACT PHONE NUMBER *

Area Code Phone Number

DOES CLUB OWN:

Boats Dock Clubhouse other

DOES CLUB LEASE/BORROW/RENT BOATS? If yes, indicate name and address of boat owners.

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

HOW MANY TOTAL MEMBERS IN THE ORGANIZATION? *

HOW MANY ARE ACTIVE MEMBERS? ("Active members" are those that participate in On and/or off water activities. Members that pay their dues but do not participate in any activities are referred to as "inactive members") *

DOES YOUR CLUB MAINTAIN DIRECTORS & OFFICERS LIABILITY?

What is the location of water you paddle in most frequently? *

ADDRESS OF PHYSICAL LOCATION (If different from mailing address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

IS YOUR CLUB CURRENTLY INSURED WITH US? *

New to Insurance Program Renewing Prior Coverage

PREMIUM CALCULATION

USE THE NUMBER OF ACTIVE PADDLERS

Definitions:

Active - A member that participants in 1 or more off and/or on water club activities.

Non-Active - A member that pays member dues but does not participate in any club activities.

CHOOSE CLASS OF WATER MOST FREQUENTLY PADDLED BELOW

Hover over a class to see the classifications:

(International Scale of River Difficulty created by the American Whitewater Association)

CLASS I-II

2-50 MEMBERS $235 51-100 MEMBERS $435 101 - 200 MEMBERS $635

CLASS I-II 201+ MEMBERS

$4.35 per member

# members *

Enter # members

201+ Members Class I-II Base Premium

CLASS III

N/A 2-50 members $295 51-100 members $585 101 - 200 members $835

CLASS III 201+ MEMBERS

$5.35 per member

# members *

201+ Members CLASS III Base Premium

CLASS III & IV (For clubs that paddle both class')

2-50 members $475 51-100 members $735 101-200 members $1,120

CLASS III & IV 201+ MEMBERS

$6.90 per member

# members *

201+ Members CLASS III & IV Base Premium

Annual Risk Program Membership Fee *

$25 (Non Refundable)

ADDITIONAL INSUREDS

$25 Per entity (non refundable)

# Additional Insureds *

Enter number of entities

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

Subtotal - additional insureds

If you would like us to insert your club logo to the waiver please upload a sample of the logo

Browse Files

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

TOTAL DUE

WILL CALCULATE - DO NOT EDIT

PLEASE SELECT PAYMENT METHOD *

Mail - Make check payable to Paddlesport Risk Management mail to: 121 Pulaski Road, Kings Park, NY 11754. Reference club name on check. Your documents will be released once payment is received. Online

READ BEFORE SUBMITTING ONLINE PAYMENT:

DO NOT CLOSE YOUR BROWSER after you finish making the payment - CLOSE THE XPRESS PAY WINDOW ONLY . Look for the "club liability application" heading along the tabs of your browser - click on it - to be directed back to this page to finish submitting the application -

If you accidently close the browser you will need to re-submit the application but do not resubmit your payment - check the mail payment option.

READ ABOVE INSTRUCTIONS BEFORE CLICKING BELOW

CLICK TO PROCEED TO PAYMENT WINDOW

Acceptance of this proposal confirms your desire to obtain insurance through the Sports, Liesure, & Entertainment Risk Purchasing Group. I hereby certify that requirements of Paddlesport Risk Management, LLC (PRM) and US Coast Guard or state laws, whichever is stricter, will be adhered to 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 PRM approved release of liability waiver.

Signature *

Clear

Name

First Name Last Name

COMMENT

LEAVE A COMMENT OR SUGGESTION TO HELP US IMPROVE OUR SERVICES

After submitting, a copy of this application will be sent to your email. Please allow 3-5 business days for processing. Coverage will start the day your application and payment have been received on or after January 1st. If you need coverage within 3 business days please use the comments box to let us know or after completing call our office. (631) 269-9696.

ANNUAL CLUB LIABILITY APPLICATION