IMBA chapter and club liability insurance and participant accident insurance

Contact Information

Contact Name

Telephone Number

Email Address

Fax

Chapter/Club Information

Name Insured (Legal Name of the Chapter/Club, entity or event to be insured

Is your organization an IMBA Chapter or Club?

Chapter
Club
Unaffiliated with IMBA

Address of Insured Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Form of Business

If an event, please list the event location and venue

Please describe the operations/activities of the chapter/club or the event - activities to be insured

Sport/Activity Information

Please list the sport(s) or activities that your organization or event is involved in

Please provide as much detail as possible, including level (i.e. professional, amateur, recreational, etc.)

Please specify the Total Number of active members (those who regularly attend your club/chapter activities) or total number of participants or participants plus spectators for your event (if applying for event only coverage). Estimate if needed.

Total number of active members or participants 12 and younger

Total number of active members or participants 13 - 15

Total number of active members or participants 16 - 18

Total number of active members or participants 19 and older

Please provide your estimated annual gross revenue

Number of teams or groups

Number of playing days including games, practices and tournaments (for period of coverage)

Total number of expected spectators

If applying for an event, please provide the number of days of your event

General Information

Please type N/A if the questions is non applicable to your application

What type of security will you be using?

Estimated total gross receipts

$ amount

Desired Accident Medical Deductible

Desired Accident Medical Benefit ($25,000 is standard. Higher limits result in higher premium cost)

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)?

Yes
No

Have you, your organization or event had any claims in the past five (5) years?

Yes
No

Does any volunteer, owner, coach or official have a criminal record or has ever had a criminal record?

Yes
No

Have you, your organization or event ever filed for bankruptcy?

Yes
No

Have you ever had insurance cancelled or non-renewed for any reason?

Yes
No

Does the applicant have risk exposure in the state of California?

Yes
No

Do you host informal group rides on a regular basis

Yes
No

Does your organization (members or volunteers) use heavy equipment?

Yes
No

Heavy equipment means backhoe, Ditch Witch, bobcats, etc.

Does your club host any special event(s) with any participants or attendees who are not included in your membership statistics above?

Yes
No

If yes, please provide the following details for EVERY special event that includes participants who are not included in your membership statistics above.

Event Name, Dates, Location (venue, city, state), Estimated # of spectators/attendees, Estimated # of participants (if athletic event), Estimated liquor receipts if applicable & Type of event. Please type "NO SPECIAL EVENTS" if this is not applicable.

Please include all information above for all special events hosted by your club that includes participants or attendees who are not already included in your membership statistics above.

Does the applicant use a waiver and release of liability?

Yes
No

Are you currently insured with a different liability insurance company?

Yes
No

If yes, please request your organization's insurance policy loss history from your current insurance company - Please provide even if you have had no losses (no prior claims) and your report should show no previous losses.

If necessary, please provide additional details/clarity to any yes or no answers from above.

Please note that the use of a waiver is mandatory for insurance coverage.

For your protection we recommend having your waiver prepared/approved by your legal council. If you do not have a waiver, or if your current waiver is in question, we recommend contacting IMBA.