David L. Murphy Insurance
Specializing in Sports Liability Insurance

 


Home  -  Info  -  Application  -  Contact Us


Hockey League or Camp Coverage
Renewal Confirmation

(if you are applying for new coverage, please click here)

Please be advised insurance is not bound until insurance company approves submitted application.

Download a .pdf version of our
Hockey League or Camp Coverage Renewal Confirmation by clicking here

or use our Online Application below

Please fill out this form and submit at the bottom of the page.


Insured Name:

Address:

City, State, Zip:

Contact Person:

Phone Number:
Email:
Website:

May we email all correspondence including policies/certificates?  Yes   No



    Additional Insured Information
    (please include a complete list of names and addresses)

    


Waiver and Release System Requirements

You must maintain a system to regularly secure signed Waiver and Release forms from participants allowed to enter restricted areas and to prevent restricted area credentials from being issued before participants have properly signed and executed the Waiver and Release forms. For minor participants (under eighteen [18] years of age), you must always maintain a system to secure valid Minor Waiver and Release forms signed by the parent or legal guardian.

Unintentional error on your part in securing Waiver and Release or Minor Waiver and Release forms will not void your coverage in the event of an "occurrence" to a participant. However, your failure to maintain an adequate system to regularly secure Waiver and Release or Minor Waiver and Release forms will void your coverage in the event of an "occurrence" to the participant.

When you notify us of an "occurrence" involving a participant, you will also provide us with a valid Waiver and Release form that has been signed and dated by the participant prior to the time of the "occurrence".

If the participant is a minor (under eighteen [18] years of age), you will provide us with a valid Minor Waiver and Release form that has been signed by the parent(s) or legal guardian(s) of the minor participant.

Does the league or camp require a completed waiver from all participants?  Yes No

 


Combined Liability and Accident Premium Calculation

League: Number of Youth: Rater per Participant: Total:
  Number of Adult: Rate per Participant: Total:
       
Camps: Total number of Youth camper days: Rate per day: Total:
  Total number of Adult
camper days:		 Rate per day: Total:

   Please attach a schedule of the camps and participants if necessary:

    

  
  Applicant's Statement and Declarations

The applicant declares to the best of his/her knowledge the information contained in this application and all supplements attached to be true and that no material facts have been suppressed or misstated. The applicant further understands that any false or fraudulent statements or misrepresentations could result in termination or voidance of any insurance contract issued from the information stated herein.

Applicant Signature:
               checking Yes will satisfy a signature requirement   Yes  No

PLEASE NOTE: You must check either YES or NO above, or the form will
automatically reset if you try to submit it.
 

 

 

David L. Murphy Insurance Agency, Inc.
10 Liberty Street,  Danvers, MA 01923
Phone: 978-777-5930

email: dlmhockey@yahoo.com

 

David L.  Murphy Insurance

Direct contact with David Murphy regarding any questions about your insurance program. The most competitive insurance rates available for camps, clinics, leagues, and tournaments.