Nicholas Hill Group

Is your Club/Chapter a current member organization of the International Mountain Bicycling Association (IMBA)? *

We provide coverage to both IMBA affiliated organization as well as those who are unaffiliated with IMBA. IMBA affiliates will receive member exclusive pricing. Membership must be confirmed to receive the member benefit.

Yes

No

Applicant (to be insured) Physical Street Address *

We must have a physical address before we can issue a policy for your club. Physical address is therefore a mandatory field.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant (to be insured) Mailing Address *

We must have a mailing address before we can issue a policy for your club. Mailing address is therefore a mandatory field.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person *

First Name

Last Name

Phone *

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###

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Business Structure *

If other, please explain below

Corporation

Joint Venture

Partnership

LLC

Other

Insured Status *

For Profit

Not For Profit

Date of Incorporation or Charter *

MM

DD

YYYY

Desired Policy Effective Date *

MM

DD

YYYY

Policy Expiration Date *

MM

DD

YYYY

Quote Need By Date *

MM

DD

YYYY

Has Applicant Had Insurance Coverage Previously *

If No, please provide an explanation below

Yes

No

Have coverages ever been canceled or non-renewed during past 5 years? *

If Yes, please provide an explanation below

Yes

No

Have you had any claims made against you or others related to actions or activities of your organization, or losses paid by your insurance company in the past 5 years? *

If Yes, please provide an explanation of all claims below

Yes

No

Does the organization build and/or maintain trails? *

Yes

No

Does the organization build or maintain trails with technical trail features (TTFs) such as bridges, ramps, etc? *

Yes

No

Does the organization build or maintain dirt jump areas, slope style courses or pump tracks? *

Yes

No

Does the organization own, operate or maintain a bike park? *

Yes

No

Does the organization hold any agreements to perform services? *

If Yes, please describe below

Yes

No

Are you providing liquor for a profit?

Yes

No

Are you required to obtain a liquor license or permit for an event, meeting or function?

Yes

No

Will your annual liquor sales exceed $20,000?

If yes, please specify estimated revenue (in $) for liquor sales below.

Yes

No

Liquor Liability Coverage *

Note: Host Liquor Liability Coverage is automatically included with your General Liability Policy. However, if you answer yes to any of the above 3 liquor liability related questions, we recommend you answer "yes" below and apply for Liquor Liability Coverage.

Yes, I would like to apply for Liquor Liability Coverage

No, I would like to Decline this Offer

Non-Owned/Hired Auto Liability Coverage

Limits of coverage: $300,000 per occurrence is only option provided

Yes, I would like to apply for Non-Owned/Hired Auto Liability Coverage

No, I would like to Decline this Offer

Does the insured have any owned automobiles?

If Yes, please provide the name of the insurer, current limits of coverage and effective date of coverage below.

Yes

No

Do members to use their own person vehicles for club purposes?

Yes

No

If insured allows employees to use their own personal vehicles, indicate the frequency of use

Daily

Weekly

Monthly

Other (please provide details below)

To your knowledge, do members who regularly use their cars for business purposes carry minimum personal auto limits?

Yes

No

Does your club rent/lease vehicles for club purposes?

Yes

No

If yes above, do you ever rent/lease 12- or 15-passenger vans?

Yes

No

Would you like to purchase $1,000,000 in excess liability coverage?

If Yes, please indicate below.

Yes, I'd like to purchase $1,000,000 in excess liability coverage.

No, I would not like to purchase excess liability coverage.

Does your club utilize Mobile Equipment (e.g. bobcats, tractors, skidsteers, augers, etc) and need coverage for liability associated with use of that equipment?

If Yes, please describe usage below.

Yes

No

Does your club engage in tree removal? If yes, are chainsaw operators certified where required by state or have undergone training (e.g. OSHA or NSCP)?

Please check all that apply below.

Yes (tree removal)

No (tree removal)

Yes (Chainsaw operators certified and/or undergone safety training)

No (Chainsaw operators certified and/or undergone safety training)

Does your organization have any of the following exposures for minors?

Please check all that apply below.

Overnight travel

Overnight accommodations

Campgrounds

Daycare

Individual coaching or potential 1:1 contact

Other (please describe below)

Do you check credentials for qualifications and/or perform screening asking about past criminal accusations or convictions including sex related offenses or child abuse for members and/or officers of your organization?

Yes

No

Has insured’s organization ever had an incident which resulted in an allegation of sexual abuse? (If yes, please describe)

Yes

No

Has coverage ever been canceled or non-renewed during past 5 years for any of the above Special Events? *

Yes

No

Have you had any claims made against you or losses paid by your insurance company in the past 5 years for any of the above Special Events?

If yes, please provide an explanation of all claims below.

Yes

No

Do any of the above events include any of the following activities: Gravel Rides, Open Road Cycling, Use of ATV's, Bungee Jumping, Fire Dancing/Walking, Firearms/Riflery, Gymnastics, Inflatable Devices, Zip Lines, Mechanical Bulls, Motor Sports, Rappelling, Rock Climbing, Ropes Courses, Scuba Diving, Trampolines, White Water Rafting, All? *

Yes

No

Do any of the above Additional Insureds require the Primary and Non-Contributory Endorsement? If so, please list those requiring this endorsement below. *

Yes

No

Do any of the above Additional Insureds require the Waiver of Subrogation Endorsement? If so, please list those requiring this endorsement below. *

Yes

No

Each Club/Chapter, Event and Additional Activity must install and collect a signed Release and Waiver of Liability, Indemnity Agreement and/or Assumption of Risk Form for all members, participants, volunteers and staff. Unintentional error on your part in securing Waiver and Release forms shall not void your coverage in the event of an occurrence to a participant or staff. However, your failure to maintain an adequate system to regularly secure Waiver and Release forms shall void your coverage in the event of an occurrence to a participant or staff. NOTE: Waiver and release program required for coverage. Do you agree to comply with this requirement? *

Please email a copy of the form that you use to [email protected]

Yes

No

A Risk Management Plan is required to purchase any of the above coverages. Do you agree to comply with this requirement? *

Yes

No

Signing this application and declaration does not bind either the application or the underwriter to provide the insurance. In the event there is any material change in the answers to the questions herein prior to the issuance date of the policy, the application form would be considered inaccurate or incomplete. The applicant will notify the insurer in writing, and, if necessary, any outstanding quotation may be modified or withdrawn. It is agreed that this application and declaration shall be attached to and form part of any policy which may subsequently be issued. To be signed by the Insured The undersigned applicant represents that the statements set forth in this application and its attachments and other materials submitted to the insurer are true and correct. In accepting any quotation provided by result of this proposal request, the insured warrants that all information and answers provided in this application are true and correct. Should an insurance policy be written, this application and any supporting information shall be incorporated into and form the basis of the written insurance policy. The Insured so warrants: *

Yes

No

By typing your name below, you are hereby agreeing to the terms outlined above and providing your personal warranty that all answers and responses that have been provided are true and accurate. Please note: All quotations are subject to the receipt and acceptable review of the application and other underwriting information by the underwriter. *

First Name

Last Name

Today's Date *

MM

DD

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