[Canadian] Tournaments|Competitions Application

Request Date    09/10/2010 06:42:45 AM

Named Insured
Address of Insured
  City
  Province
  Country
  Postal code
Form of Business
Contact Name
  Telephone Number
  Fax     
  Email
Organization Type
Affiliations
   Provincial    National    International
 
Please describe the operations/activities to be insured: 
Sport/Activity
Level
Number of participants 17 and younger
 
Number of participants 18 and older
Total Number of participants
Number of Teams
If cover for another Sport/Activity is sought, please check next next
 
What type of security will you be using?
Maximum number of spectators at any individual event or location
Estimated Total Gross Receipts $
 
REQUESTED EFFECTIVE DATE (Activity Start Date):
REQUESTED EXPIRY DATE (Activity End Date):

Will you be using any, pyrotechnics, or use of mechanical devices that will be ridden (excluding sporting equipment)? 
If yes, please describe, in detail, any use of special effects, pyrotechnics, or use of mechanical devices, etc.: 
Does any volunteer, owner, coach or official have a criminal record, or has ever had a criminal record? 
If yes, please explain: 
Have you had any claims in the past five (5) years? 
If yes, please describe any losses you have incurred over the past five (5) years, and provide insurance company loss runs: 
Have you ever filed for bankruptcy? 
If yes, please explain: 
Have you ever had insurance Cancelled, or Non Renewed for any reason? 
If insurance has been declined or cancelled, please explain: 

Please note that eligibility for insurance coverage under this programme requires that the applicant
  • utilize the client waiver available here (to download, right click and select 'Save Target').

    • Coverage Limits
      Limit of Liability: $2,000,000 (CAD) with a $2,000,000 (CAD) aggregate
      Accident and Medical (Included): $10,000 (CAD)
     

    Does the applicant require certificate(s) of insurance? 
    Does the applicant require certificates of insurance for Additional Insureds? 



    DECLARATION
    To the best of my knowledge and belief all statements made in this Application for Insurance are true. Signing of this document does not bind the Applicant to complete the insurance, but it is agreed that this Application shall be the basis of the contract, should a policy be issued.
     
     
    Copyright 2010©SportsInsurance.com        Read our Privacy Policy and Terms and conditions        Check out our Affiliate program