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 (excluding racing 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

CityState / Province

Postal / Zip Code

CONTACT NAME*

First NameLast Name

Designation: (ie President, VP, Treasurer,etc)*

We recommend providing a generic club email address. This avoids important emails from our office being rejected when a prior club members personal email address is no longer valid.

CONTACT EMAIL *

example@example.com

CONTACT PHONE NUMBER *

Area CodePhone Number

DOES CLUB OWN:

BoatsDockClubhouseother

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

If owner of boats is not the club please add name of owners

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

HOW MANY TOTAL MEMBERS IN THE CLUB/ORGANIZATION?*

HOW MANY ARE ACTIVE MEMBERS? ("Active members" are those that participate in On and/or off water activities even if they participate in 1 paddling session or social function. Members that pay their dues but do not participate in any on or off water activities are referred to as "inactive members")*

DOES YOUR CLUB MAINTAIN DIRECTORS & OFFICERS LIABILITY?

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

Name of Lake, River, Ocean and township located in

ADDRESS OF PHYSICAL LOCATION (If different from mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

IS YOUR CLUB CURRENTLY INSURED WITH US?*

New to Insurance ProgramRenewing 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. They support the club financially.

CHOOSE CLASS OF WATER MOST FREQUENTLY PADDLED BELOW. IF YOU HAVE MEMBERS THAT PADDLE IN SPECIFIC CLASS' YOU MAY BREAK THE CLASS' UP. Please call for help with this section if necessary. (631) 321-6859

Hover over class code if you are not sure which one to select:

CLASS I-II

2-50 MEMBERS $31051-100 MEMBERS $550101 - 200 MEMBERS $805

CLASS I-II 201+ MEMBERS

$5.50 per member

# members *

Enter # members

201+ Members Class I-II Base Premium

CLASS III

2-50 members $36751-100 members $705101 - 200 members $1,030

CLASS III 201+ MEMBERS

$6.65 per member

# members*

201+ Members CLASS III Base Premium

CLASS III-IV (Water is primarily class III with sections of class IV)

2-50 members $54551-100 members $870101-200 members $1,320

CLASS III-IV 201+ MEMBERS (see above class description)

$8.15 per member

# members*

201+ Members CLASS III-IV Base Premium

SAILBOATS - Club Owned - Liability

$165 Per Boat

# Boats*

SAILBOAT TOTAL

NON REFUNDABLE: Annual Risk Program Membership Fee - the pre-paid option is for clubs that joined new to program between Sept-Dec 2022*

$25 ( All Clubs except those noted below)Pre-paid between 09/01/2022 - 12/31/2022 as a new club to program

ADDITIONAL INSUREDS REQUIRED*

NOYES ($25 per entity)

# Additional Insureds*

Enter number of entities

Subtotal - additional insureds

PLEASE READ BEFORE SELECTING CERTIFICATE TYPE:

If you are asked to provide specific endorsements please upload a copy of the permit/lease insurance requirements using the UPLOAD button below or email to paddlesports@jacka-liquori.com. Endorsements must be issued by the insurance company and can take between 2-4 business days. Please confirm the entities name/address details as municipalities tend to change these frequently. Changes due to not checking will delay processing and not given priority.

IF YOU HAVE NOT BEEN ASKED TO PROVIDE ANY ENDORSEMENTS DO NOT CHECK THE ENDORSEMENT BOX. You will be provided an addtional insured certificate of insurance.

A fee of $25 per entity is charged for additional insureds. In the event of an incident that results in a suit beging filed against the club, it's members and any addtional insured, the club policy will not only pay defense and judgement costs to defend the club and its members but will also pay defense costs for the additional insureds named.

If specific wording is requested please type into the comments box at the bottom. ONLY REQUEST ENDORSEMENTS IF YOU HAVE BEEN INSTRUCTED BY THE CERTIFICATE HOLDER otherwise check the Additional Insured Certificate box only.

Additional Insured CertificateWaiver of Subrogation30 Days Cancellation NoticeState or Municipality Endorsement CG 20-12Additional Insured Person/Organization Endorsement CG 20-26

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

ELECTRONIC WAIVERS:

An electronic waiver system is available for clubs to access. Your club name and/or logo can be added to the generic waiver. Any specific wording/information lines can also be added. (discussed prior to creation of waiver). We recommended using a generic email address for notifications of a signed waiver 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. This reduces the responsibility of a member having to collect paper waivers. You will be given a link to post to your websites/social media pages or to email to members and guests. You will have access to a back office where you will see all signed waivers and be able to download. Up to 8 members can be added to access the back office. You will not be able to edit, remove or delete any data this can only be done by request to our office. It is a simplifed cost effective system for clubs looking to reduce the use of paper. A PDF waiver is also provided for on-site use.

The cost is $35 per year.

CHOOSE TYPE OF WAIVER - You may use both PDF and E waiver*

PDF WaiverPRM E-Waiver - Renewal - $35PRM E-Waiver New- $35Currently Using Alternative E-Waiver system

Email address all electronic signed waivers will be forwarded to:

example@example.com

Use the upload feature to attach a copy of your logo or any other document you wish to submit with this application.

UPLOAD YOUR FILE

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

TOTAL PREMIUM DUE

Paddlesports Program Information Outline - Please download a copy for your file. It contains policy terms, definitions, limits and other important information about the club liability program.

TERMS AND CONDITIONS

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

I also confirm that I will download the safety regulations and incident reporting packet and will review the safety rules with club members and guest paddlers.

Entering your name to accept terms & conditions

First NameLast Name

COMMENT

LEAVE A COMMENT OR SUGGESTION TO HELP US IMPROVE OUR SERVICES

Payment - Please indicate payment method. If mailing - application will not be processed until check is received. PLEASE NOTE: WE DO NOT SEND OUT INVOICES PREMIUM MUST BE PAID ONLINE OR BY MAIL*

Mail (see mailing info below)Online (No vendor fee for check payment. Vendor fee acccessed for credit/debit card. You will be redirected after you submit your application)

Mail in payment: Make check payable to Paddlesport Risk Management, LLC

Mail to: 121 Pulaski Road, Kings Park, NY 11754

Phone: (631-321-6859)

A COPY OF THIS APPLICATION WILL BE EMAILED TO THE EMAIL ADDRESS PROVIDED

Thank you for your support of our paddlesports program. If you love our service please leave a review on Yelp; Google Reviews or Facebook.

PADDLES UP!!

2023 ANNUAL CLUB LIABILITY APPLICATION