Clubs and Associations Form | Bicycle Broker Insurance

Contact Person

First Name *

Last Name *

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City

State/Province

Postal Code

Company Name

Date Founded

Expiry of Existing Policy

Structure of your business

Annual Gross Revenue

Please breakdown % of annual revenue per operation

Business Operations Description

What type of group do you operate? *

Number of Full Time Employees

Number of Part Time Employees

Do you require signed waivers?YesNo

Do you have any US or Foreign sales?Yes, US RevenueYes, Foreign RevenueNone

Do you own or rent your physical space?OwnRent

Estimated Revenue $ *

What is your clubs estimated final member count this year?

Do you have any race, speed, or timed events or other larger special events or festival planning during the upcoming year?YesNo(regular weekly rides are not deemed an event)

Does your club have winter fat biking or any other Winter Activities?YesNo

Does your club "own" any cabins, clubhouses, or storage sheds, C-Cans, shelters?YesNo

Does your club own any equipment?YesNo

Do you have a Bike or Skills park?YesNo

Do you own, maintain, operate or sign any trails?YesNo

Please elaborate *

Is there other Insurance in place on any of the above trails? *YesNo

Who is responsible for maintenance, inspection and engineering? *

Do you have man made trail " features " designed on your trails? *YesNo

If so, provide details of the types of features how many are involved. Photos or links that show the features very helpful (many liability incidents arise from features, they should be designed and with signage to IMBA standards). *

Upload Photos

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Are there Gravity Mountain bike trails (ex. Mountain/Ski Hill descent trails)YesNo

Does your club provide Cycling Valet Parking Services?YesNo

List all activities of the club:(such as meetings, membership drives, trail activities, non-cycling activity etc.)

If you are required to provide Certificates of Insurance please provide details on each Additonal Insured (Legal business name, address and why they need to be named):

Amount of CGL requested

Deductible Requested

Property/Stock Limit Requested

Has the business been involved in any claims in the last 5 years?YesNo

If yes, please provide a description, including dollar amount paid or held in reserve?

Has the applicant ever been declined or cancelled by an insurance company?YesNo

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Clubs & Associations Form

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