Purchase Basketball Insurance Protection Plan

Are you a new Customer?     Yes       No  

Are you a current customer requesting a Renewal Policy?     Yes       No  

Select Policy Term (select one):       6-Months       Annual

Premium Computation

In order to apply for the General Liability Insurance, you must first apply for the Accident Medical Insurance (see below).

Mandatory Accident Medical Premium Calculation

Ages 12 & Under*

X Rate

+ Ages 13-15

X Rate

+ Ages 16-18

X Rate

= Sub-Total (Minimum of $150)

General Liability Premium Calculation

Requires Accidental Medical Insurance above completed first.

Number of Eligible Participants

Number of Eligible Staff

x Rate

Additional Insured's (Request for certificate of insurance)

Requires General Liability Insurance above completed first.

Number Required

x Rate

= Sub-Total

Optional Coverage

Hired and Non-Owned Automobile Liability

Information

Limit $1,000,000 Premium - $1000

Dishonesty Bond

Information

Limit $25,000 Premium - $165.00 ($150 per bond + $15 Fee)

Contents/Sports Equipment/Inland Marine Coverage

Information

Purchase Contents/Sports Equipment/Inland Marine

Select your coverage: Limit              Premium $5,000           $150.00 $10,000          $250.00 $15,000          $375.00 $20,000          $500.00 $25,000          $625.00

(Includes $20 certificate license fee.)

Mailing Address, if different

Location of Activity:

Does your organization utilize a waiver system?     Yes       No  

Does your organization have a risk management plan?     Yes       No  

Have you had any losses? Yes No

If yes, please attach number of losses, description for each and amount paid.

Does the property where you are conducting the activity require a Certificate of Insurance (additional insured)?     Yes       No  

List additional insured name(s) and address(es)

If you were helped by a Westpoint Insurance agent today please enter their name:

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Premium is fully earned on the effective date of coverage. No pro-rata refunds will be made. Cancellation requests prior to the effective date must be in writing and subject to a minimum cancellation fee of $75.00. I understand and agree that (a) if this application is accepted by the Company, coverage will begin on the date of acceptance or the date requested in the application, whichever is later, subject to payment of the required premium; and (b) Premium computation is subject to audit. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Please check the box to verify and agree that the information provided herein is
true and complete.
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