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2015-2016 APPLICATION FOR ROLLER DERBY CERTIFICATE OF INSURANCE
To obtain the special liability insurance coverage for USA Roller Sports sanctioned competitions described on the reverse side of this form, you
must submit this application to USA Roller Sports at least 30 days prior to the date your certificate is required. Applications received less than 30
days prior may be denied coverage by the insurance company due to short notice.
Name of Individual Completing Application:
Complete Mailing Address:
Email Address:
Phone:
Sponsoring Club Name: Club ID:
Name of Event: Date of Event:
If applying for a blanket certificate, the above line can be left blank (N/A).
Specific Location of Practices/Activities (Facility Name and Complete Address):
Type of Certificate Requested:
Single Roller Derby Event at Chartered or Non-Chartered Facility ($100 per day) *
Blanket Certificate for Entire Season at Chartered Facility ($200) *
*The first five certificates, whether single or blanket, are no charge.
Will additional insureds need to be added to this certificate? ____Yes____No If yes, list below:
Name: Relationship:
Please attach a list if necessary.
Do you have a contract with the venue? _____Yes _____No
If yes, a COMPLETE copy must be included with this application. By signing below, applicant agrees to include the following
paragraph in any venue contract:
"It is agreed and understood that USA ROLLER SPORTS (USARS) shall not be liable for any loss, injury or damage to persons or property arising from
circumstances or conditions connected with the facility which are not under USARS' control or which are not due to the negligence of USARS, or not
directly related to USARS' use of the premises."
By signing below, applicant acknowledges that they have had an opportunity to review the insurance policy in place for all USARS members and
clubs, understands the contents and limitations contained therein, and have had an opportunity to ask any questions regarding said insurance policy.
Applicant's Signature:
Date: Amount Enclosed:
USA Roller Sports
4730 South Street
Lincoln, NE 68506
402.483.7551 phone 402.483.1465 fax
CREDIT CARD INFORMATION
Card Number:
CCV#:
Expiration Date:
Billing Zip Code:
Name on Card:
Signature:
Total Amount To Charge:
Please only use ONE of the methods below. Duplicate
returns may result in duplicate charges and delayed processing.
MAIL completed form and check or credit card information to:
USA Roller Sports, 4730 South Street, Lincoln, NE 68506
FAX completed form and credit card information to:
402.483.1465
EMAIL completed form and credit card information to:
Q
uestions? Call 402.483.7551.
Roller Hockey Certificate Template
source: teamusa.org
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