Event Insurance Application

Applicant
Region*
Permit #
Organizing Club*
Acronym*
Club Contact
Name*
Position of Applicant*
Phone*
Email*
Event Details
Type of Event*
CIRCUIT (Cars) EVENTS*
PERFORMANCE DRIVING EVENTS*
ICE RACE (Cars) EVENTS*
RALLY EVENTS*
SOLO EVENTS*
KARTING EVENTS*
ANNUAL CLUB COVERAGES*
Category*
NOTE: Additional events to be entered after the order is processed. Instructions will be sent via email.
Name of Event*
Event Start Date*
Event End Date*
Number of Days*
Name of Competition Facility*
Location of Competition Facility*
Additional Insured
Setup, Tear Down dates and Notes
If less than 14 days before the event, please add Late Fees ($50)
Total
$ 0.00 CAD
*
- I am authorized on behalf of the affiliated club to apply for event insurance.
Select Payment method*
- PayPal
- E-Transfer or Cheque

Applicant