Agent Amateur Teams/Leagues Coverage Change Form *If you would prefer to print and submit this form please click here for the 2021 change request PDF. *Rating Chart for policies effective 3/01/2019 – 2/29/2021. *Rating Chart for policies effective 3/01/2021 – 2/29/2022. Step 1 of 3 33% General Information Named Insured (As it appears on your certificate of Insurance)* Policy Number (As it appears on your certificate of Insurance) Agnet submitting change* First Last Agent Phone* Agent Email* Are you the agent that bound this policy?* Yes No Name of contact First Last Contact Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Exposure Information Notes: You must submit this request form prior to the effective date needed. Coverage will be made effective the day after this request form and payment are received, or on a later date that you may specify. All participants ware required to be reported. TBD numbers cannot be accepted. A roster may be requested as verification. Refer to the Amateur Sports Teams, Leagues & Association brochure for sport eligibility, coverage option classifications and rates. For limits above $2,000,000, please contact us for a quote. Should you have $1,000,000 of Sexual Abuse or Sexual Molestation Liability coverage in place with us, you will need to rate for this additional exposure with any increments you may add below on the next page. 1. Does your team, league or organization include any of the following sports?* Yes No Cheerleading (age 19 & under), Deck/floor/street hockey, Field hockey, Flex Football™ (age 19 & under), Lacrosse (age 19 & under), Roller hockey (quad), Soccer (age 19 & under), Tackle & contact football (age 19 & under), Umpire/referee associations for Class C sports, Water hockey (age 19 & under), or Wrestling (age 19 & under) If yes, please check those that apply* Cheerleading (age 19 & under) Deck/floor/street hockey Field hockey Flex Football™ (age 19 & under) Lacrosse (age 19 & under) Roller hockey (quad) Soccer (age 19 & under) Tackle & contact football (age 19 & under) Umpire/referee associations for Class C sports Water hockey (age 19 & under) Wrestling (age 19 & under) If you suspect an athlete has a concussion, do you have an action plan in place?* Yes No Does your action plan include immediately removing the athlete from play or practice?* Yes No Does your action plan include keeping the athlete out of play or practice until they provide written clearance from a licensed physician?* Yes No Does your operation include tackle or contact football?* Yes No Do you maintain a system for your tackle or contact football activities that includes communication (in written or electronic form) of education materials to participants, parents and coaches about the nature of risk of concussions, including but not limited to information such as: focusing on prevention and preparedness to keep athletes safe; understanding concussions and potential consequences of the injury; recognizing concussion symptoms and how to respond; and learning about steps for returning to play after a suspected concussion?* Yes No Program Liability Please select what you are trying to change on your current policy below* Adding additional participants to existing sport and age group Adding new sport and/or age group Changing coverage limits to current policy Adding new coverage to my existing policy Other Please indicate that you understand the information below:* I agree: Class C Sports have limited Brain Injury coverage. Should you wish to exclude this coverage, please contact us. * Brain Injury limit/Aggregate limit: $1,000,000 / $1,000,000 * Loss Adjustment Expense limit/Aggregate limit: $ 1,000,000 / $ 1,000,000 Brain injury” means concussion, chronic traumatic encephalopathy or any other injury to the brain and any symptoms, conditions, disorders and diseases, including death, resulting therefrom but only if such injury occurs as a result of specific events occurring during the policy period. Effective date needed for change* MM slash DD slash YYYY How many sports are you adding to your policy?* 1234+ First Sport to be Added* Please select the age groups you need to add for your first sport.* 12 & Under 13 - 15 16 - 19 20 & Over Please list the number of participants within the age group of 12 and under for your first sport.* Please list the number of participants between the age of 13-15 for your first sport.* Please list the number of participants within the age group of 16-19 for your first sport* Please list the number of participants within the age group of 20 and over for your first sport* Second Sport to be Added* Please select the age groups you need to add for your second sport.* 12 & Under 13 - 15 16 - 19 20 & Over Please list the number of participants within the age group of 12 and under for your second sport.* Please list the number of participants between the age of 13-15 for your second sport.* Please list the number of participants within the age group of 16-19 for your second sport* Please list the number of participants within the age group of 20 and over for your second sport* Thrid Sport to be Added* Please select the age groups you need to add for your third sport.* 12 & Under 13 - 15 16 - 19 20 & Over Please list the number of participants within the age group of 12 and under for your third sport.* Please list the number of participants between the age of 13-15 for your third sport.* Please list the number of participants within the age group of 16-19 for your third sport* Please list the number of participants within the age group of 20 and over for your third sport* Fourth Sport to be Added* Please select the age groups you need to add for your fourth sport.* 12 & Under 13 - 15 16 - 19 20 & Over Please list the number of participants within the age group of 12 and under for your fourth sport.* Please list the number of participants between the age of 13-15 for your fourth sport.* Please list the number of participants within the age group of 16-19 for your fourth sport* Please list the number of participants within the age group of 20 and over for your fourth sport* Please indicate if you need to add more than 4 more sports to your policy. Please be sure to indicate the number of participants needing to be added per age group. Example: (Baseball - 12&under - 15 participants. Softball - 13-15 - 2 participants.) Please indicate which changes you would like to make:* I want to increase my General Liability limit I want to increase my Accident/Medical limit Other policy coverage Change organization name, contact, address, etc. New General Liability limit requested:* New Accident/Medical limit requested:* Other policy/coverage change requested - Describe below* Please note, you can only add additional coverages if you currently have General Liability. Change Organization name, contact name, address, etc. - Describe below:*
