Directors and Officers

Application for Non-Profit Member Clubs Part 1
Please answer all questions
Applicant Club Name ("Applicant"):
Contact Person:Cell Phone:
Mailing Address:Business Phone:
City, State ZIP:, Home Phone:
E-Mail:Fax:
The applicant is a member
of USA Swimming or Masters?		 Did the applicant purchase
this type of coverage last year?
Have any dishonesty, burglary, robbery, disappearance, destruction or forgery losses
been discovered by the insured in the last six years?
If yes, please give specific details.

If no losses please proceed to self-rate.