Facility User Program
SHORT FORM INSURANCE APPLICATION (SPORTS)
Name of Organization:
*
Mailing Address:
*
Street Address
Street Address Line 2
City
Province / Territory
Postal Code
Contact Name:
*
First Name
Last Name
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Describe the activity to be insured:
*
Number of Participant Members:
*
Age of Participants:
*
Number of Clubs/Teams:
*
Coaches:
Rows
Number of Paid Coaches
Number of Volunteer Coaches
Coaches
Number of Officials/Refs/Umpires:
*
How many events per policy term:
*
Any Provincial/National activities:
*
Are all practices, Contests and events sanctioned by an association? If yes, referral is required.
*
Yes
No
Are waivers signed? If no, we are unable to write.
*
Yes
No
If Hockey, are there any Jr A or B players? If yes, referral is required.
Yes
No
Describe any medical, security procedures for the tournaments, etc.:
*
Will there be liquor served at any of the activities? ?If yes, referral is required.
*
Yes
No
Please provide details:
*
Effective Date:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Expiry Date:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Additional Comments:
Signature:
Position:
*
Full Name:
*
First Name
Last Name
Date:
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: