SECTION V. EXPOSURE
11.
a. Number of participants: BY AGE: 12 & Under:
16-18: ______
19 and up: _____
b. Maximum Age:
12. Amount of Exposure by each Participant (# of events, meetings, length of season, tournaments, etc.):
______________________________________________________________________________________
13. Requested dates of coverage: From(MM/DD/YYYY): __________________ To(MM/DD/YYYY): ____________________
SECTION VI. PARTICIPATION
14. Yes No Are volunteers included in the exposure?
If yes, how many volunteers? _______________________
SECTION VII. OTHER INFORMATION
1. The undersigned declares that to the best of his/her knowledge the statements herein are true. Signing of this Application does not
bind the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy
be issued, and this Application will be attached and become part of such Policy, if issued. Underwriters hereby are authorized to make
any investigation and inquiry in connection with this Application as they may deem necessary.
2. It is warranted that the particulars and statements contained in the Application for the proposed Policy and any materials submitted
herewith (which shall be retained on file by Underwriters and which shall be deemed attached hereto, as if physically attached hereto)
are the basis for the proposed Policy and are to be considered as incorporated into and constituting a part of the proposed Policy.
3. It is agreed that in the event there is any material change in the answers to the questions contained herein prior to the effective date
of the Policy, the Applicant will notify Underwriters and, at the sole discretion of Underwriters, any outstanding quotations may be
modified or withdrawn.
4. For purposes of creating a binding contract of insurance by this Application or in determining the rights and obligations under such a
contract in any court of law, the parties acknowledge that a signature reproduced by either facsimile or photocopy shall be the same
force and effect as an original signature and that the original and any such copies shall be deemed one and the same document.
Signed: _____________________________ Print Name:
Title: _______________________________ Date (Mo/Day/Yr): ________
Applicant Organization:
Participant Accident - Amateur Sports Application 011521 Page 2 of 2 aliverisk.com
13-15:
Alive Risk is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a subsidiary of Ryan Specialty Group,
LLC (RSG). Alive Risk works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the public. Some products may only be available in certain states, and some
products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC (License # 0G97516). ©2021 Ryan Specialty Group, LLC
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