Establishment/Personal Information

Request Date
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Establishment/Insured information
Name
Name of owner(s)
Address
City
Province
Country
Postal code
Phone number
Fax number
E-mail
Web Site
Yrs. in operation
Affiliations
Provincial
National
International
Contact information
Name
Address information same as above
Address
City
Province/State
Country
Postal/Zip code
Phone number
Fax number
E-mail
Agent/Broker information (if applicable)
Name
Phone number
Fax number
E-mail
Desired coverage dates
Desired effective
Desired expiry

Participants

	total	females	males
below 6
age 6 to 13
age 14 to 18
age 19 to 34
age 35 to 65
age 66+

Participant members (Total)
Clubs/Teams
Paid coaches
Volunteer coaches
Officials/Umpires/Refs
Directors/Officers

Additional Named Insured
Please list those entities which you are CONTRACTUALLY OBLIGATED to list as Additional Insured.
*If the additional insured is an owner, manager, or lessor of the premises, please indicate the name and street address of the premises leased or rented to you by the designated additional insured, with respect to your activity or operation.

Name	Address	Role

Applicant for this insurance is a: Corporation Team Owner/Operator League Partnership Association

Important

I hereby warrant and confirm that the above information, to the best of my knowledge, is true and correct, and further certify that I have read all of the questions and answers of this application. I understand this application is a requirement for coverage, a part of the contract and evidence of my acceptance of this insurance, and any falsification or misrepresentation will be deemed a breach of contract, voiding all insurance coverage. It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or to SportsInsurance until accepted by the company or companies in writing.

I Agree