Type of Policy............................ |
Rodeo
Volunteer |
Name of Association................... |
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Street Address........................ |
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City, State Zip......................... |
,
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Name of Rodeo Arena................. |
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Street Address........................ |
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City, State Zip......................... |
,
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Performance Dates..................... |
From:
/
/20
To:
/
/20
Total Workers:
|
Coverage Needed........................ |
From:
/
/20
To:
/
/20
|
__
Limits......................................
......... |
__
Accidental Death & Dismemberment:......... $5,000.00**
Excess Medical: .......................................$5,000.00**
Deductible: $100.00
Volunteers only (no arena or livestock pen workers) $325* per event; $475 Annual
Volunteers including arena or livestock pen workers) $400* per event; $550 Annual
- OR -
Accidental Death & Dismemberment:......... $10,000.00
Excess Medical: .......................................$10,000.00
Deductible: $100.00
Volunteers only (no arena or livestock pen workers) $650* per event; $950 Annual
Volunteers including arena or livestock pen workers) $800* per event; $1,100 Annual
*Call for rates if more than 150 volunteers are to be covered
**Eligibility requirement for Participant Liability on Arena or Livestock pen workers in General Liability program is $10,000 limit of Accident and Dismemberment & Excess Medical for Qualified sanctioned events
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Name of Contact Person............ |
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Social Security # or Tax ID#..... |
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Phone Number........................ |
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Fax Number............................ |
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E-Mail Address........................ |
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Address of Rodeo Committee..... |
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City, State Zip......................... |
,
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Comments: |
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