HULL INSURANCE QUOTE REQUEST

You are submitting this application for hull physical damage under Paddlesport Risk Management's RPG Master Hull Policy. The policy term runs from 09/15 - 09/15. This policy is physical damage only and does not include liability. If you are a club/org/assoc with a club liability policy under PRM or USDBF liability will be extended from your club policy.

If you schedule your boats/kayaks/canoes midway through a policy term your first year premium will be pro-rated. Each club/association/organization/individual is endorsed to the master policy with their scheduled boats.

This program is available to all members of Paddlesport Risk Management or the United States Dragon Boat Federation. Coverage is also available for individuals. If you are not a member of either of a club or association you can still access coverage. Your quote will include a membership fee of $25 (annual).

This is an All Risk policy for physical damage only and includes racing and training for racing.

Please indicate the organization you are a member of. *

Paddlesport Risk Management Club A USDBF Club Affiliate Individual Non member organization

NAME OF INSURED/CLUB/ ORGANIZATION OR ASSOCIATION *

CONTACT PERSON *

First Name Last Name

Mailing address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Date you want coverage to start

Month Day Year

Is mooring/docking or storage location same as mailing address *

Yes No

Mooring/Docking or Storage Location *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone number *

Area Code Phone Number

E-mail *

Confirmation Email

Describe security measures at storage/mooring location *

INDICATE WHAT BOATS WILL BE USED FOR *

Race Training Racing (may be transported over land) Social Club - no racing

Hull Details *

	HULL TYPE eg. (Outrigger, DragonBoat, Rowing Shell etc)	YEAR BUILT	MAKE/MODEL	SERIAL OR ID NUMBER	MATERIAL	LENGTH	VALUE TO INSURE
1
2
3
4
5
6
7
8
9
10

Do you have a trailer to add? *

Yes No

Trailer *

	YEAR	MAKE/MODEL	SERIAL OR VIN#	STORAGE LOCATION	REPLACEMENT VALUE
1
2

Name up to 3 responsible users (if a Club/Assoc/Org) : *

	FULL NAME	Age	RELATIONSHIP TO BOAT OWNER (OWNER, CLUB PRES, COACH, ETC)	Years Paddling Experience
1
2
3

Waters where vessel/s will be used primarily: *

Indicate name of River, Lake, Ocean and township

Do you currently have insurance coverage? *

No Yes

Name of current insurance carrier?

Expiration date of current insurance carrier?

Have any paid loss' occurred within the past 3 years?

No Yes

MANDATORY: Describe loss type, amount paid, date loss occurred. You will be required to request up to 5 years loss experience reports from your prior insurance carrier.

Notes/comments:

Add any additional information; suggestions or feedback

By inserting my name below I warrant that the information provided is true to the best of my knowledge and that quotes offered will be based on this information.

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First Name Last Name

Date *

Month Day Year

A copy of this application will be emailed to the address you listed above. A quote will be emailed to you within 48 hours. If you need coverage immediately please indicate in the comments box above.