2024 USMCA Insurance Program Application

2024 USMCA Insurance Program Application

Active USMCA Certification Required
First and Last Name (as it appears on Driver's License or Passport):*

First NameLast Name
Business Name (if applicable):*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Certification Training Type:*

Dirt BikeSport BikeDual-Certified (Dirt+Sport)
Years of Coaching Experience:*
Areas of Specialization:*

Training Days Per Year:*

	Completed in 2023	Planned for 2024
Estimated Training Days

Training Facilities (for more than 5 facilities, please email to support@usmca.org)*

I understand that I am applying for the USMCA Insurance Program, which will be bound once the USMCA receives payment and K&K Insurance issues a Certificate of Insurance (COI). Please note that coverage will begin on 2/1/2024 or the payment date, whichever is later, and it will expire on 2/1/2025. This insurance is in excess of a primary event coverage policy expected to be in place. This policy is designed for coaches actively coaching at track day events, schools, practices, and races where the event promoter or manager provides primary insurance coverage.

I acknowledge I have received my USMCA Certified Coach certificate, and I am eligible for the USMCA Certified Coach Insurance Program. I understand that I will receive confirmation of insurance and a PDF copy of the Certificate of Insurance directly from K&K Insurance via email.
Signature*

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