HULL INSURANCE QUOTE REQUEST

You are submitting this application for coverage under Paddlesport Risk Management's RPG Master Hull Policy. The policy term runs from 09/15 - 09/15. If you schedule your club or associations boats during the policy term your first year premium will be pro-rated. Each club is endorsed to the master policy with their scheduled boats.

This program is available to all members of Paddlesport Risk Management or a USDBF Club member. If you are not a member of either of these you can 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.

DOES YOUR CLUB/ASSOCIATION HAVE CLUB LIABILITY INSURANCE THROUGH ONE OF THE FOLLOWING *

Paddlesport Risk Management A USDBF Affiliate NO

NAME OF INSURED CLUB/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 of 3 responsible users: *

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: *

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 24 hours. If you need coverage immediately please indicate in the comments box above.