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Quotation Information
(Active)
Policy Information
Confirmation
Please note that this Policy is written on a claims-made basis. An extended reporting period my be available on this Policy. Please refer to the Policy Form or contact us for details.
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Phone:
877-441-4011
E-mail:
express@americanspecialty.com
Questionnaire/Eligibility
Please enter all information on the screen.
Please confirm that you are a member club of League of American Bicyclists
Yes
No
Do you have more than 5 paid full-time employees? (Do not include employed/contracted coaches in your count)
Yes
No
Have there been any legal actions, written demands or other type of Directors & Officers Liability or Employment Practices Liability claims against the Applicant within the past 3 years?
Yes
No
Estimated number of club rides in a calendar year
Estimated number of club members
Annual Budget or Revenues for the most recent 12 month period
Directors & Officers Liability insurance has been continuously in force for the Applicant since
In Force Date
Popup Calendar: In Force Date
Expected format: MM/DD/YYYY
(MM/DD/YYYY)
Policy Effective Date
Popup Calendar: Policy Effective Date
Expected format: MM/DD/YYYY
(MM/DD/YYYY)
Has the Applicant or any Director or Officer proposed for coverage herein been the subject of,
or involved in, any of the following in the past five (5) years
Antitrust or copyright/patent litigation
Any disciplinary action by any regulatory agency or association
Any action where a license was revoked or suspended
Any administrative proceeding charging violation of a federal or state law or regulation
Any other criminal activity
None of the above
Has the Applicant given written notice under the provisions of any prior policies providing similar
insurance or claims, or of specific facts or circumstances which might give rise to a claim being
made against any person or entity applying for this insurance?
Yes
No
Are you aware of any facts or circumstances which you have reason to suppose might give rise to a future
claim that would fall within the scope of any of the proposed coverages for which the Applicant has applied?
Yes
No
With respect to this coverage, has any Underwriter refused, canceled or non-renewed coverage?
Yes
No
Electronic signature / disclaimer (Please type your name)
Comments (if applicable)
Coverage Limit
$1,000,000
$2,000,000
NOTE: Higher coverage limits may be available through an offline submission process. Please contact us at amerspec@americanspecialty.com for additional information.
Club Name
Address
City
State
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip
County
ADAIR
ALLEN
ANDERSON
BALLARD
BARREN
BATH
BELL
BOONE
BOURBON
BOYD
BOYLE
BRACKEN
BREATHITT
BRECKINRIDGE
BULLITT
BUTLER
CALDWELL
CALLOWAY
CAMPBELL
CARLISLE
CARROLL
CARTER
CASEY
CHRISTIAN
CLARK
CLAY
CLINTON
CRITTENDEN
CUMBERLAND
DAVIESS
EDMONSON
ELLIOTT
ESTILL
FAYETTE
FLEMING
FLOYD
FRANKLIN
FULTON
GALLATIN
GARRARD
GRANT
GRAVES
GRAYSON
GREEN
GREENUP
HANCOCK
HARDIN
HARLAN
HARRISON
HART
HENDERSON
HENRY
HICKMAN
HOPKINS
JACKSON
JEFFERSON
JESSAMINE
JOHNSON
KENTON
KNOTT
KNOX
LARUE
LAUREL
LAWRENCE
LEE
LESLIE
LETCHER
LEWIS
LINCOLN
LIVINGSTON
LOGAN
LYON
MADISON
MAGOFFIN
MARION
MARSHALL
MARTIN
MASON
MCCRACKEN
MCCREARY
MCLEAN
MEADE
MENIFEE
MERCER
METCALFE
MONROE
MONTGOMERY
MORGAN
MUHLENBERG
NELSON
NICHOLAS
OHIO
OLDHAM
OWEN
OWSLEY
PENDLETON
PERRY
PIKE
POWELL
PULASKI
ROBERTSON
ROCKCASTLE
ROWAN
RUSSELL
SCOTT
SHELBY
SIMPSON
SPENCER
TAYLOR
TODD
TRIGG
TRIMBLE
UNION
WARREN
WASHINGTON
WAYNE
WEBSTER
WHITLEY
WOLFE
WOODFORD
Website
Year Established
State of Incorporation
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
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