ESIX  

PURCHASE INSURANCE

To purchase coverage online, there are certain eligibility criteria that must be met. Please complete the following to determine eligibility.

1. Are you currently a non-profit member club of United States Field Hockey Association, Inc.?   Yes    No
 
2. Do you have more than 5 paid employees? (do not include employed or contracted coaches in your count)   Yes    No
 
3. Have there been any legal actions, written demands, or other type of claims against the Applicant within the past 3 years?   Yes    No
 
4. Number of members in the applicant’s club/association:
 
5. Annual revenues for most recent 12 month period:
 
6. Directors & Officers Liability insurance has been continuously
in force for the Applicant since:

Note: if your organization has not purchased Directors & Officers coverage
previously, please enter your preferred policy effective date.

 
7. Has the Applicant or any Director or Officer proposed for coverage herein been the subject of, or involved in, any of the following in the past five (5) years:
  Antitrust, copyright or patent litigation
  Any disciplinary action by any regulatory agency or association
  Any action where a license was revoked or suspended
  Any administrative proceeding charging violation of a federal or state law or regulation
  Any other criminal activity
  None of the above
 
8. Has the Applicant given written notice under the provisions of any prior policies providing similar insurance or claims, or of specific facts or circumstances which might give rise to a claim being made against any person or entity applying for this insurance?   Yes    No
 
9. Are you aware of any facts or circumstances which you have reason to suppose might give rise to a future claim that would fall within the scope of any of the proposed coverages for which the Applicant has applied?   Yes    No
 
10. With respect to the coverage, has any Underwriter refused, canceled, or non-renewed coverage?   Yes    No
 
11. Electronic signature / disclaimer (Please type your name):
 
12. Comments (if applicable):
 
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