Ages 12 & Under
= Accidental Medical Sub-Total (Minimum of $150) General Liability Premium Calculation
Requires Accidental Medical Insurance above completed first.
Number of Non-Tackle Participants
Number of Tackle Participants
Number of Cheerleading Participants
= Sub-Total (Minimum of $550) Additional Insured's (Request for certificate of insurance)
Requires General Liability Insurance above completed first.
x Daily or Weekly Rate
= Sub-Total Optional Coverage
Limit $1,000,000 Premium - $1000
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.
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