Insurance Program and Enrollment Form

Transcription

1 MOTORSPORTS INDEPENDENT CLUB EVENT LIABILITY Insurance Program and Enrollment Form PROGRAM DESCRIPTION This program has been designed for U.S.-based Car Clubs. We offer affordable general liability protection for your club s car shows, meetings, rallies, and social functions. While participating in your covered activities, the general liability coverage extends to your officers, members, and volunteers. Excess liability limits are available. The program automatically includes Products Liability (food or drink) and $1 million Commercial General Liability. Legal Liability to Participants (LLP), which applies to motorized events and protects your club if it is found to be legally liable for a participant s injuries, is included. (LLP coverage is effective only upon receipt of each participant s signature on a Release and Waiver of Liability Agreement provided by K&K Insurance Group, Inc.) For your competitive events, such as autocrosses, gymkhanas or rallies, we can also provide general liability for officials, car owners, drivers, pit crews, sponsors, advertisers, and any person or organization operating, managing, sanctioning, sponsoring or providing the premises for your covered program. ELIGIBLE OPERATIONS Independent Clubs Organizations operating the premises for covered programs Autocross Business Meetings Caravans Concours Gymkhanas Parade Participants Poker Runs Rallies Slaloms Social Functions Tours Other one car at-a-time events Motorcycle Clubs (refer to company for underwriting and pricing) Off Road Events (refer to company) Coverage is provided by a carrier rated A+ (Superior) by A.M. Best Company. INELIGIBLE OPERATIONS Wheel to Wheel Racing Boating Risks Hill Climbs Drifting WAYS TO ENROLL FOR COVERAGE Submit this enrollment form, with payment, to K&K. KK_motorsports@kandkinsurance.com FAX MAIL Regular: Overnight: This brochure is for illustrative purposes only and is not a contract of insurance. You must refer to the actual coverage document for complete information regarding coverage terms, conditions and exclusions as they may change from one coverage term to the next. You may request a copy of the full policy by submitting a written request to K&K Insurance Group, Inc. K&K Insurance Motorsports/ICEL P.O. Box 2338 Fort Wayne, IN QUESTIONS Call K&K Insurance Motorsports/ICEL 1712 Magnavox Way Fort Wayne, IN /11

2 Abuse, molestation, harassment or sexual conduct All operations listed as ineligible Amusement devices (eg: rides, slides, inflatables, bungees, climbing walls or devices, dunk tanks) EXCLUSIONS The following represent only some of the exclusions contained in this policy. Asbestos Employment-related practices Fireworks Fungi or bacteria COVERAGES AND LIMITS Lead Nuclear energy liability Pollution Coverages - Annual Coverage for Business Meetings and Social Functions. Commercial General Liability Car Clubs Limits Each Occurrence $ 1,000,000 General Aggregate (Other than Products-completed Operations) None Products-completed Operations Aggregate (food and drinks) $ 1,000,000 Personal and Advertising Injury $ 1,000,000 Damage to Premises Rented to You $ 300,000 Legal Liability to Participants $ 1,000,000 Expense Reimbursement for Competition Vehicles Damage Claims (90% co-payment) $ 100,000 Official Vehicle Property Damage ($1,000 deductible) $ 1,000,000 Errors and Omissions $ 100,000 Minimum Premiums $ * Contact K&K at if higher limits are needed * Coverage provided under this program includes: Commercial General Liability coverage which protects the insured against liability claims for bodily injury and property damage arising out of premises, operations, products and completed operations and personal and advertising injury. Legal Liability to Participants coverage which offers protection against bodily injury liability claims brought by persons participating in covered programs. Page 2 of /11

3 FREQUENTLY ASKED QUESTIONS 1. What coverages are available? Our basic plan offers general liability protection, with limits of $1 million. (Excess limits are available by request). Legal Liability to Participants protection, with coverage limits matching the General Liability, and Products Liability Protection (Food and Drink), are also included. 2. When is the insurance effective? Your insurance will be effective when we ve received your completed plan application and premium payment and approved the risk. You should receive your coverage documents and all necessary supplies to administer your insurance program within 30 days of the effective date of your coverage. 3. Do I need to notify you of club events? You should provide a schedule of events to K&K, but you do not need to notify us prior to each of your non-competitive events, such as business meetings and social functions. However, competitive events, such as autocrosses, gymkhanas or rallies, and other public events operated by your club, such as parade participation and car shows are not included in the basic membership premium and require that you arrange for coverage at least two weeks before the event. Contact us for an event premium quotation and supplemental application. ICEL CRITERIA year old driver requirement and 16 year old passenger requirements. (Applies only as respects Non-Spectator Events as noted on page 5. Refer to K&K if any deviation.) 2. K&K approved Waiver and Release must be signed by all persons entering a restricted area. 3. Because Sports Car Club events are considered private events, members of the general public must be denied access to the event premises. 4. The conduct of any event is subject to the rules and regulations of the association. Page 3 of /11

4 Independent Club Event Liability (ICEL) Insurance Application Completion of this enrollment form confirms your desire to obtain insurance through the Sports, Leisure and Entertainment Risk Purchasing Group. An RPG provides group purchasing power for similar risks resulting in potential advantageous coverage terms, competitive rates, risk management bulletins, and rewards for favorable group loss experience. The submission of this enrollment form and/or acceptance of payments does not guarantee coverage. Certain operations are not eligible for coverage by this program. K&K reserves the right to decline any request for coverage. Name of Insured (as will appear on policy): Doing Business As: Mailing Address: City: State: Zip: Phone: ( ) Street Address: City: State: Zip: Phone: ( ) Contact Person: Person is: m Owner m Promoter m Agent m Other: Day Phone: ( ) Cell Phone: ( ) Fax: ( ) Address: Web Site Address: Name of Agency/Brokerage (if applicable): Contact Person: Mailing Address: City: State: Zip: Phone: ( ) Fax:( ) address: Tax ID #: Nature of operations/description of event: Insured is: m Corporation m Partnership m Joint Venture m Limited Liability Corporation m Other (explain): In what state is the organization headquartered/chartered? Policy period requested: From To UNDERWRITING INFORMATION Has this type of insurance ever been: m Cancelled m Declined m Non-renewed If so, please explain. (Not applicable in Missouri) Does this organization engage in any other business operations under the name of the insured as it will appear on the policy? m Yes m No If yes, please explain. As respects your operation(s), do you enter into any contracts? m Yes m No If yes, what contracts do you enter into? Please submit an Independent Club Event Liability (ICEL) Event Coverage form for each event along with this application. Also, please review, acknowledge compliance of, then sign and return the Autocross event minimum insurance qualifications for any Autocross events. Page 4 of /11

5 ANNUAL MEMBERSHIP Car Clubs: Per member rate subject to a minimum earned premium of $500: m Members: $6.20 per member x Number of Club Members = Membership Premium $ m Members: $4.40 per member x Number of Club Members = Membership Premium $ m 501 or More Members: $3.05 per member x Number of Club Members = Membership Premium $ EVENT COVERAGE Event coverage premium from Independent Club Event (ICEL) coverage form(s): Event #1 premium $ Event #3 premium $ Event #5 premium $ Event #2 premium $ Event #4 premium $ Event #6 premium $ TOTAL PREMIUM 1. Club membership premium ($500 minimum): $ 2. Total premium for all events: $ 3. Risk Purchasing Group membership fee: $ $10.00 Total premium due (add lines 1 through 3): $ Coverage available for the following club activities and events. Additional premiums apply. Refer to the attached Independent Club Event (ICEL) Event Coverage Form for applicable premiums Car Club Non-Speed Activities: Class I Auctions Car Washes Guided Tours Public* Breakfasts/Dinners Public* Dances/Shows Public* Picnics Public* Receptions/Seminars Car Shows/Concours Class II Parade Participants Poker Runs/Toy Runs Rallies (autos only, no motorcycles) Non-Spectator Events: Autocross, Gymkhana, Slalom, Solo II Solo I (except Hillclimbs) Time/Speed/Distance (TSD) Rallies Additional event types must be referred to K&K Insurance Group, Inc. for Underwriting, Approval, and Rates. *Public means non-members of the club (not including immediate family of members). Page 5 of /11

6 Independent Club Event Liability (ICEL) Event Coverage Form IMPORTANT NOTICE: An ICEL EVENT INSURANCE COVERAGE must be submitted for each event, prior to the event, in order to validate insurance coverage. Failure to comply will result in NO INSURANCE coverage for your competitive event. IF A CERTIFICATE OF INSURANCE IS NEEDED, PLEASE SUBMIT THIS ORDER TWO (2) WEEKS PRIOR TO THE EVENT TO INSURE PROPER MAIL TIME. 1. Name of Insured Club: Address: City: State: Zip: 2. Event Date: 3. Event Location (name of site): Address: City: State: Zip: Class I, 0-50 Miles, Attendance 1-250: $154 Per Day Class I, 0-50 Miles, Attendance : $190 Per Day Class I, Miles, Attendance 1-250: $177 Per Day Class I, Miles, Attendance : $219 Per Day Class II, 0-50 Miles, Attendance 1-250: $190 Per Day Class II, Miles, Attendance 1-250: $219 Per Day Autocross, Gymkhana, Slalom, or Solo II: Solo I: TSD Rally: $200 Per Day $475 Per Day $120 Per Day Any certificates required for additional insureds? m Yes m No If yes, what is their relationship to the club? m Manager or Lessor or Premises (i.e.: landowner) m Sponsor Additional Insured Information: Name: Address: City: State: Zip: Name and address of premises rented/leased to the insured if applicable: Name: Address: City: State: Zip: Name and address of premises rented/leased to the insured if applicable: Waiver and Release Requirement: Each event participant MUST sign the K&K Waiver and Release of Liability and Indemnity Agreement. The appropriate signed waiver must be forwarded to K&K upon request only, and is a condition of Participant Legal Liability coverage. A supply of these forms was mailed to the club insurance representative when the ICEL policy was issued. Should you require more forms, please check below and indicate the quantity needed for your remaining events of the year. Please send Waiver and Release forms. Name of person completing this order: Address: City: State: Zip: Daytime phone: ( ) Fax: ( ) Note: Policy endorsement for this event and certificate, if requested, will be returned to the person completing this order. Page 6 of /11

7 GENERAL FRAUD STATEMENT Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN, and VA, insurance benefits may also be denied) APPLICABLE IN COLORADO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE IN THE DISTRICT OF COLUMBIA WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. APPLICABLE IN FLORIDA Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. APPLICABLE IN HAWAII For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. APPLICABLE IN KANSAS Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. APPLICABLE IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. APPLICABLE IN MINNESOTA Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN OHIO Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. APPLICABLE IN WASHINGTON It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Page 7 of /11

8 Select Payment Plan: Check one: m 100% Plan 100% of the total premium is due to bind coverage m Check here if you prefer to be mailed an invoice for any future balances/installments. PAYMENT INFORMATION If paying by credit card, any outstanding balances or installments will be charged to the same card number provided below, unless you have checked the box above. Making your Payment: m Check: Please make check payable to K&K Insurance Group, Inc. Enclosed is check # for $ m Credit Card: If you are making your payment by credit/debit card, please complete the following: m VISA m MASTERCARD m DISCOVER m AMERICAN EXPRESS Card number: Reference number (last 3 digits on back of card): Expiration date: I authorize K&K Insurance Group, Inc. to charge my payment to my credit card in the amount of $ Print name (as on card): Cardholder signature COVERAGE EXCLUSIONS The following exclusions are contained in the commercial general liability coverage provided by this program. Abuse, molestation, harassment or sexual conduct; Aircraft/hot air balloon; Airport; Amusement devices (the ownership, operation, maintenance or use of: any mechanical or non-mechanical ride, slide, or water slide, any inflatable recreational device, any bungee operation or equipment, any vertical device or equipment used for climbing-either permanently affixed or temporarily erected, or dunk tank. Amusement devices do not include any video or computer games or any device that is specifically designated for the training or instruction of the activity for which you are enrolled.); Animals (injury or death to, or injury, death or property damage caused by any animal owned, rented or hired by you); Asbestos; Boating activities; Commercial general liability standard exclusions (CG /04 edition); Employment-related practices; Fireworks; Fungi or bacteria; Haunted attractions; Lead; Nuclear energy liability; Performers (injury or death to any performer or entertainer during any activity, event or exhibition including but not limited to any stunt, concert, show or theatrical event. This exclusion does not apply to participants in any activity, event or exhibition that are part of the designated operations for which you are enrolled) Page 8 of /11

9 READ AND SIGN WARRANTY AND DISCLOSURE STATEMENT I understand that the insurance company, in determining whether to provide insurance coverage, will rely on the information contained in this form and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. K&K Insurance Group, Inc. as managing general underwriter for the insurance company, receives compensation from the insurance company in consideration for its performance of insurance services that include, but are not limited to; underwriting, policy/certificate issuance, administration and claims handling. The insurance company compensates K&K, based on a predetermined calculation of thirty-three percent of the total premium. The total may also include an annual RPG membership fee up to ten dollars. I am aware that the insurance company expects accurate reporting for my premium calculation. I understand that my books and records may be examined or audited by the insurance company at any time during the coverage period and up to three years thereafter. Intentional misrepresentation or misreporting may jeopardize coverage. I further acknowledge that I have reviewed all information provided with this enrollment form and understand the exclusions which apply, as well as the activities and operations for which coverage is not provided. Applicant signature: Date: Printed name: Title: If an agent: Check here to acknowledge you are signing on behalf of the named insured. m Named insured (from page 5): PLEASE NOTE: Your event premium check must be postmarked at least one day prior to the event to which this order pertains to have insurance in effect and valid. We cannot accept competitive event requests by phone. If your order form or premium payment is incomplete or in error, we will attempt to phone you to correct the error. Coverage is valid only if the order form is completed correctly and appropriate premium is remitted. If your club s premium payment check is not honored by your bank for any reason, the failure of premium payment will jeopardize your coverage for the event to which the check pertains. After one check has been returned by your bank for non-payment, all subsequent future insurance orders will be accepted only on a certified-check or money-order basis without exception. If you need a certificate of insurance, or your policy endorsement prior to the event, mail this application at least two weeks in advance to assure you receive the certificate in time. Faxes and telegrams confirming coverage cannot be guaranteed. Page 9 of /11

10 Autocross Event Minimum Insurance Qualifications K&K INSURANCE GROUP, INC. for the insuring Company, shall be permitted, but not obligated, to inspect the IN- SURED S property and operation for UNDERWRITING AND/OR LOSS CONTROL PURPOSES at any time. Neither the right to make an UNDERWRITING AND/OR LOSS CONTROL INSPECTION nor the making thereof, nor any report thereof, shall constitute an undertaking, on behalf of or for the benefit of any insured, or others, to forecast any accident or its severity or determine or warrant that such property or operations are safe or healthful, or are in compliance with any engineering standards, rules or regulations. THE ESTABLISHMENT OF UNDERWRITING QUALIFICATIONS AND UNDERWRITING AND/OR LOSS CONTROL INSPECTIONS ARE FOR THE SOLE PURPOSE OF DETERMINING THE INSURABILITY OF CERTAIN PROPERTY AND OPERATIONS, underwriting, and seeking to reduce claims against insurance and are not for the benefit of any insured or third party. The Insured is solely responsible for the safety of its property and operations and shall not rely upon any Underwriting and/or Loss Control Inspections or activities to determine the safety of its property or operations and shall not diminish or forego its own safety practices and procedures. I. EVENT DESCRIPTION An autocross or Solo II event is a COMPETITIVE EVENT, driving skill contest conducted on courses that emphasize car handling and agility rather than speed or power. The course generally consists of STRAIGHT sections and connecting TURNS or corners, as marked by pylons, generally resembling a miniature road course. II. EVENT SITES A. The event is held on a flat surface. B. RESTRICTED AREAS; must include, at a minimum, the course surface, the area within the circumference of the course, and all other areas within 100 feet of the outside of the course, and the PIT AREA. C. VIEWING AREAS: Must be designated explicitly. Must be located beyond the 100 foot RESTRICTED AREA. The boundary between the Viewing Area and the RESTRICTED AREA will be established with at least rope and banner; a fence of some kind is strongly recommended. SPECTATORS are restricted to the Viewing Areas. D. PERMANENT, REAL, FIXED PROPERTY (buildings, trees, light stanchions, similar physical obstructions): May not be closer than 25 feet to the course in STRAIGHTS and/or inside of TURNS, not closer than 75 feet on the outside of the TURNS. E. PARTICIPANTS are not covered by participant accident insurance unless specifically purchased for that event. III. EVENT MANAGEMENT A. Basic rules and standards for conduct of events must be drawn up before an event is run and be available to all drivers. B. An event chief official must be appointed to supervise the running of the event. C. Event Safety Official(s) are strongly recommended. Their sole responsibility should be to monitor the safety of the event. One safety official should be on-duty at all times. D. All PARTICIPANTS must sign the current K&K waiver form. PARTICIPANTS under the age of majority in the state in which the event is run (or under the age of 18 or which ever is greater) must have a current K&K Minor Release and Waiver of Liability and Indemnity Agreement signed by his/her parent(s). Other waiver forms may not be used. E. All drivers must have a valid driver s license. Any license or permit which requires another licensed driver in the AUTOMOBILE is not acceptable. Minor drivers must be able to show that they have permission to operate the AUTOMOBILE in the event. F. All drivers must wear a D.O.T. approved helmet, and must use seat lap belts. G. Participants are permitted to ride as passengers in the AUTOMOBILE during training sessions and driving schools. Participants are permitted to ride as passengers during the competition run only with the approval of the event chief official. All passengers must meet the requirements of section D & E; Must be in an AUTOMOBILE which has passed technical inspection; Must wear seat belt and approved helmet; Must have signed a waiver. The passenger must be either a student riding with an instructor or an instructor riding with a student during a drivers school. H. FIRE EXTINGUISHERS: There must be at least two 10 BC rated dry chemical fire extinguishers on site and in proper working condition. IV. COURSE REQUIREMENTS A. When laying out a course, the size of the AUTOMOBILES competing should be taken into consideration. The following guidelines are minimum qualifications for insurability. 1. Speeds on STRAIGHT stretches should not exceed 70 m.p.h. for the fastest class of automobiles. The fastest portions of the course shall be those most remote from Page 10 of /11

11 SPECTATORS and property. Speeds at turns should not normally exceed 45 m.p.h. 2. The course should contain no holes, loose gravel, gratings, oily spots or dips in the course. V. COMPETING AUTOMOBILES A. All AUTOMOBILES shall be subject to a strict inspection by qualified technical inspectors. B. Driver/passenger restraints: Seat lap belts are required in all AUTOMOBILES. Installation of the shoulder belts or harnesses is strongly recommended in AUTOMOBILES with fixed tops or roll bars. Two-strap shoulder harnesses shall not be worn in open automobiles, which are not equipped with roll bars. C. Roll bars: Roll bars are strongly recommended in all automobiles. Roll bars are REQUIRED in all purpose-built competition cars and any other open cockpit AUTOMOBILES using racing (non-d.o.t. approved) tires. VI. DEFINITIONS AUTOMOBILE means a Sports Car or any selfpropelled four wheel land motor vehicle, including vehicles entered in NON-SPEED EVENTS, but does not include mobile equipment. COMPETITIVE EVENT means supervised events such as gymkhanas, time/speed/distance rallies, autocrosses, slaloms, field trials, time trials and similar non-racing one-car-at-a-time events. COMPETITION VEHICLE means any self-propelled vehicle, land motor vehicle or watercraft on the premises for the specific purpose of competing or performing in a covered program. PARTICIPANT means any person that you grant permission to enter the restricted area but only if: A. The person has clearly defined duties directly allotted to them as respects a covered program ; and B. The person is within the restricted area. PIT AREA means the area used to register the PARTICIPANTS and prepare the AUTOMOBILES for the event. RESTRICTED AREAS means any area requiring special authorization, credentials or permission to enter and to which admission by the general public is restricted or prohibited including but not limited to the PIT AREAS, course surface, the area within the circumference of the course and all other areas within 100 feet of the outside of the course. SPECTATOR means any person who is not a PARTICIPANT nor a member of the general public unassociated with the club. STRAIGHT means a section of the course at least 50 feet in length in which the AUTOMOBILE does not substantially change direction. TURN is any section of the course which is not STRAIGHT. I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. Applicant s Signature Applicant s Name (print) Date (MM/DD/YY) Producer s Signature (if applicable) Producer s Name (print) Date (MM/DD/YY) Page 11 of /11