HULL INSURANCE QUOTE/CHANGE 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.

What do you want to do?*

APPLY FOR NEW POLICYMAKE A CHANGE TO EXISTING POLICY

Select changes you want to make?*

Add BoatAdd TrailerRemove BoatRemove Trailer

Please indicate the organization you are a member of.*

Paddlesport Risk Management (PRM) ClubA USDBF Club AffiliateIndividual -(member of a club under USDBF or PRMNon member individual/club/organization ($25 RPG Membership)

NAME OF INSURED/CLUB/ ORGANIZATION OR ASSOCIATION*

What year was club/organization formed?

n/a for individuals

CONTACT PERSON *

First NameLast Name

Phone Number: *

000-000-0000

E-mail*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date you want coverage/change to start - (coverage cannot be backdated)

MonthDayYear

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

YesNo

Mooring/Docking or Storage Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Describe security measures at storage/mooring location*

INDICATE WHAT BOATS WILL BE USED FOR*

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

Enter boat and Hull Details - TO ADD OR REMOVE A BOAT FROM EXISTING POLICY TYPE A (ADD) OR R (REMOVE) N (NEW POLICY)*

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

Is boat leased/financed?*

NOYES

Name & Address of Loss Payee/Finance Company.

The cost to add a loss payee to your vessel is $100

Do you have a trailer to add/remove?*

YesNo

Trailer *

	YEAR	MAKE/MODEL	SERIAL OR VIN#	STORAGE LOCATION	REPLACEMENT VALUE	A=Add R= Remove N= New Policy
1
2

Name up to 2 members who can be contacted in the event of an incident/claim: (if a Club/Assoc/Org) :

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

Waters where vessel/s will be used primarily:*

Indicate name of River, Lake, Ocean and township and state

Do you currently have insurance coverage?*

NoYes

Name of current insurance carrier?

Expiration date of current insurance carrier?

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

NoYes

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.

Sign

First NameLast Name

Date*

MonthDayYear

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.