Directors and Officers

Application for 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
United States Swim School Association?		 Did the applicant purchase
this type of coverage last year?
Is any person or entity proposed for coverage aware of any fact or circumstance or any actual or alleged act, error or omission, which he or she has reason to suppose might give rise to a future claim that would fall within the scope of the proposed coverage?
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.