Recreation Group or Club Enrollment Form

GENERAL INFORMATION

Name Insured:
Name Insured Is:	Individual Partnership Corporation Other:
Mailing Address:
City:
State:
ZIP:
Contact Name:
Phone:	( ) - ext.
Fax:	( ) -
Email Address:
Website:
Event Start Date:	/ /
Event End Date:	/ /
Coverages Requested:	Accident Medical General Liability Accident Medical & General Liability

UNDERWRITING INFORMATION

Describe all events, activities and operations you are requesting insurance coverage for:

Schedule of Activities:

Activity	Date	Time	Location Name/Address	Estimated Attendance

Number of Participants:

Youth:
Over 18:
Volunteers:

Are you contractually obligated to name an owner, manager, lessor of premises or any other person or entity as additional insured? If yes, list below:

Additional Insured Name	Address	Relationship to You

PRIOR INSURANCE INFORMATION
Provide minimum three years information.

Year	Company	Type of Claim	Claim Amount

AGENT INFORMATION If you are an agent, please fill out the following:

Your name:
Agency name:
Agency Address:
City:
State:
ZIP:
Email address:

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