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Ancillary Event Liability Insurance - Application

Exclusively for USA Cycling sanctioned events/races*

If you estimate that your event will exceed a combined total of 10,000 participants and spectators, you must complete the form below to apply for the USA Cycling Ancillary Event Liability Insurance Program.  Once submitted, your application will be reviewed by an underwriter and your quotes will be emailed directly to you for consideration.

Thank you for this opportunity to be of service!

USA Cycling Member Ancillary Event Liability Insurance Program
by Nicholas Hill Group, Inc.

Is your event currently sanctioned by USA Cycling? *
Please note: Although you can receive a quotation for coverage by submitting this form, you cannot purchase or bind coverage until you first sanction your event with USA Cycling and receive confirmation that your event partcipants are therefore covered by the USA Cycling event insurance policy that provides liabilty and participant accident insurance for the actual race and race related activities. This ancillary event coverage specifically excludes the actual race, race related activities and race participants.
Note: This is the name that will appear on your Certificate of Insurance. If your company is a Sole Proprietorship, then this will be your personal name or DBA
Contact Name *
Contact Name
Phone *
Phone
Address *
Address
Coverage - Start Date *
Coverage - Start Date
The date that your insurance coverage should begin
Coverage - End Date *
Coverage - End Date
The date that your insurance coverage should end
Event - Start Date *
Event - Start Date
The date that your event begins, including set-up
Event - End Date *
Event - End Date
The date that your event ends, including take down
Please include all of the non-race event details, including types of ancillary, non-race related activities that your event will inlcude that that you are applying for insurance to cover (i.e. expo, concert, beer garden, camping, etc.)
Would you like a quote for Liquor Liability Insurance Coverage? *
Please note, the ancillary event liability insurance policy will automatically include "host liquor liability" coverage. However, if any one of the 3 following criteria questions results in a β€œyes” answer, it is recommended that you purchase full liquor liability insurance protection. 1. Is policyholder in the business of manufacturing, selling, distributing, liquor? 2. Is policyholder required to obtain a liquor license or permit for event? 3. Is policyholder providing liquor for a profit? Please note, The liquor permit/license must be issued to the Policyholder name in order to be valid. If you would like to apply for Liquor Liability Insurance, please email a copy of the liquor permit/license to us at info@nicholashillgroup.com.
We must receive the name and full address for each additional insured party. Please separate each requested additional insured party by a space below.
Have you filed any Event Liability Insurance claims in the past 5 years? *
If yes, please provide full details below.
If you answered yes above, please provide full details below:
Has your event ever been cancelled? *
If yes, please provide full details below.
If you answered yes above, please provide full details below:
$
Does your event include Overnight Camping? *
If yes, please provide the estimated total number of campers and the number of nights camping is allowed 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 selecting YES or NO below *
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. You acknowledge that you are submitting an application for insurance, and that your typed name below constitutes your signature, acceptance and agreement as if actually signed by you in writing. You further acknowledge and agree that the taking of any such actions by you evidence your intent to sign any such agreement, acknowledgment, consent, terms, disclosures or conditions. You also agree that no certification authority or other third party verification is necessary to the validity of your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any resulting contract. 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. You acknowledge that you are submitting an application for insurance, and that your typed name below constitutes your signature, acceptance and agreement as if actually signed by you in writing. You further acknowledge and agree that the taking of any such actions by you evidence your intent to sign any such agreement, acknowledgment, consent, terms, disclosures or conditions. You also agree that no certification authority or other third party verification is necessary to the validity of your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any resulting contract. Please note: All quotations are subject to the receipt and acceptable review of the application and other underwriting information by the underwriter.
Please note: this 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 with any product questions. All insurance products are provided by licensed representatives.
Agent Signature: Ryan E. Hill
Agency: Nicholas Hill Group, Inc.

* These benefits are only available to USA Cycling Sanctioned Events.    

INSURER

The Ancillary Event Liability and Participant Accident coverage are provided by
U.S. Fire Insurance Company, "A" (Excellent) rated by A.M. Best Company.