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event Liability & Participant Accident insurance application


Please add each of your race events to be covered (additional activities can be added in the field(s) below).
Are you a current Running USA member Member? *
This benefit is only available to active Running USA members. You are welcome to apply for a quote, but coverage cannot be bound until membership is verified.
Note: If you need to change the dates below at any time, please contact us; you may not be covered otherwise
First Day of Event *
First Day of Event
Begin with the date that set up begins
Last Day of Event *
Last Day of Event
End with the final day of dismantlement
Do not include your volunteers or staff members - these individuals are covered under the group accident and general liability policies
Please include the following for each additional event needing coverage - Event Name, Event Location, Event Organizer (individual or entity to be covered), First Day of Event (include set up dates), Last Day of Event (include dismantlement dates), Estimated Total Number of Participants (do not include your volunteers or staff members - these individuals are covered under the group accident and general liability policies.
Additional Activities to be covered
Please enter additional activities you would like to cover. If any of these activities are scheduled outside of the event dates listed above, please adjust the coverage dates below.
Additional Activities
Please check all that apply
Frequency, duration and estimated number of participants (do not include volunteers or staff members - these individuals are covered under the group accident and general liability policies
Frequency, duration and estimated number of participants (do not include volunteers or staff members - these individuals are covered under the group accident and general liability policies
Frequency, duration and estimated number of participants (do not include volunteers or staff members - these individuals are covered under the group accident and general liability policies
Frequency, duration and estimated number of participants (do not include volunteers or staff members - these individuals are covered under the group accident and general liability policies
Frequency, duration and estimated number of participants (do not include volunteers or staff members - these individuals are covered under the group accident and general liability policies
Frequency, duration and estimated number of participants (do not include volunteers or staff members - these individuals are covered under the group accident and general liability policies
Coverage Period
The coverage period should include the dates of all of your races and additional activities
First Day of Coverage *
First Day of Coverage
Last Day of Coverage *
Last Day of Coverage
Would you like to add Annual Day-to-Day Office Premises Coverage for an additional premium of $250? *
This is annual office/premises general liability coverage
Underwriting Information
Has your past liability coverage been cancelled in any way in the last three years? *
If yes, please provide an explanation below:
Each Event and Additional Activity must install a Release ad Waiver of Liability and Indemnity Agreement for all participants 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. A full supply of Waiver and Release forms shall be emailed to you upon request. Do you agree to comply with this requirement? *
A Risk Management Plan is required to purchase this policy. Do you agree to comply with this requirement? *
Does your event include any of the following activities: 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? *
If yes, please provide an explanation below:
Optional Coverages
Non-Owned/Hired Auto Liability Coverage *
Select One Option:
$5,000.00 Spectator Medical Payments Coverage *
Would you like to add $5,000.00 Spectator Medical Payments Coverage for an additional Premium of $10.00?
$100,000.00 Sexual Abuse and Molestation Liability Coverage *
Would you like to add $100,000.00 Sexual Abuse and Molestation Liabiltiy Coverage for an additional Premium of $1,000.00?
Additional Insureds
Please add any additional insureds that are required below
Running USA, 954 Dana Lane, Waukesha, WI 53189
Running USA is automatically added as an Additional Insured to all policies
To add Additional Insureds, please include the following for EACH Additional Insureds - Legal Name, First Name, Last Name, Address, City, State, Zip Code, Email, Relationship to the Insured (Venue, Municipality, Contractor, etc.) and any required certificate verbiage.
Do any of the above Additional Insureds require the Primary and Non-Contributory Endorsement? If so, please list those requiring this endorsement below. An additional premium of $100.00 will be added for each Additional Insured that requires this endorsement. *
Please list each Additional Insured that requires the Primary and Non-Contributory Endorsement below.
Do any of the above Additional Insureds require the Waiver of Subrogation Endorsement? If so, please list those requiring this endorsement below. An additional premium of $100.00 will be added for each Additional Insured that requires this endorsement. *
Please provide details or type "NO" below
PLEASE READ AND SIGN (By typing your name) BELOW:
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: *
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. *
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.
Date 4 *
Date 4
Please note: this event insurance application is subject to full underwriting. The decision to provide a quote or not is, in part, determined by the answers you have provided in the above application. Should a policy be issued, it will include certain exclusions and limitations. It is the applicant/insured's responsibility to read and understand the terms in any policy that is issued and bound. Not all insurance products are available in all states. Please contact the Nicholas Hill Group, Inc. by emailing info@nicholashillgroup.com with any product questions. All insurance products are provided by licensed representatives.
Agent Signature: Ryan E. Hill
Agency: Nicholas Hill Group, Inc.