Tackle Football, Wrestling, Rugby and Lacrosse Protection Plan

Instructions:
Please enter the information below to complete the application for the Tackle Football, Wrestling, Rugby and Lacrosse Protection Plan. Once you have entered the required information, click the button below 'Continue to Payment' and you will be brought to the payment gateway. Please call Westpoint Insurance toll-free (800) 318-7709 if assistance is required with this form.

Are you a new Customer? Yes No

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

Requested Effective Date: *

Expiration Date:

For extended policy terms please complete a Quote Request or call (800) 318-7709 to recieve a custom quote.

Premium Computation

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

Accident Medical Premium Calculations

Select your sport:

Select deductible:

Ages 9 & Under*

X Rate

Ages 10-12

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 Tackle Participants

X Rate

= Sub-Total (Minimum of $550)

Additional Insured's (Request for certificate of insurance)

Requires General Liability Insurance above completed first.

Total # Additional Insured

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:

=Grand Total

(Includes $20 certificate license fee.)

Email: *

Contact Name (Last, MI, First) *

Phone: *

Web Address:

Fax:

Mobile/Cell:

Name of Policyholder (Team, Squad, Association) *

Mailing Address, if different*

City:*

State:*

Zip: *

Mailing Address, if different

City:

State:

Zip:

Location of Activity:

City:

State:

Zip:

Does your organization utilize a waiver system? Yes No

Does your organization have a risk management plan? Yes No

Activity to be Covered: *

Name of Present Carrier: *

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)

Name:

Address:

City:

State:

Zip:

Name:

Address:

City:

State:

Zip:

Name:

Address:

City:

State:

Zip:

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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.

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