Swim America
General Liability/Secondary Accident Application 05/15/2008 through 5/15/2009 Part 1
Please answer all questions
Application Type:
New Application
Renewal
Is your Team currently registered with SwimAmerica:
Yes
No
If "No" please contact us immediately.
Named Insured (Swim Club Name):
Website Address:
Entity Type:
Individual
Partnership
Corporation
Non Profit Org.
Other
Contact Person:
Cell Phone:
Title/Position Held
Business phone:
Mailing Address:
Home Phone:
City, State ZIP:
,
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
E-Mail:
Fax:
Experience of Applicant:
Previous Loss History (any claims?):
Previous Carrier:
Policy #:
Number of coaches/ instructors?
Are they authorized to use their own vehicle for business purposes?
Yes
No
Are they authorized to rent vehicles?
Yes
No