If you would like to download this application and send it in via mail or fax, please click here for the pdf version

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PLEASE SUBMIT THIS APPLICATION TWO (2) WEEKS PRIOR TO THE EVENT TO ENSURE PROPER MAIL TIME. FULL PAYMENT IS REQUIRED BEFORE ANY APPLICATIONS WILL BE SUBMITTED.

Is this a National Motorsports Approved Location? (*)
No, we have never had insurance at this location beforeYes, we have had insurance at this locationUnsure if it is approved or not
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1. Club, Association or Promoter: (*)

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Physical Location

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Mailing Address (*)

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City (*)

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State (*)
Please Select A State:AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
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Zip (*)

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Phone (*)

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Fax

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Email

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2. Type of Event
Motocross (Race and / or Practice)Riding SchoolSupermotoHare ScrambleEnduroPoker RunFun DayTrail RideFlat / Dirt TrackIce RacingMud Run (stock machine)Mud Run (modified machines)Dirt DragSingle File Time TrialATV PullATV ChallengeVintage MotocrossMini Bike RaceAMA Pro MX
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3. Facility Name

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4. Special Event Dates (trail rides, club rides, etc)

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Practice Dates:

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Race Dates

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Estimated Number of Participants Per Day (*)

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5. Is Alcohol Served (*)
NoYes
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If yes, what is the name on the liquor license?

Invalid Input Please provide the name of the liquor license holder.
6. Additional Insured and Relationships

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7. What is your event, club or promoter web site address?

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8. Do you have any special requests?

Invalid Input If you have a special request, please provide it here.
9. Do you need any approved waivers?
NoYes
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Do you have a procedure to ensure that all minor participants have on file the signed parental consent waiver and release? (*)
YesNo
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Are you aware that minor participants must read, complete and sign only the minor waiver each time they participate in a covered program? (*)
YesNo
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Is a National Motorsports approved waiver and release form read, completed and signed by all participants before entering the restricted area and participating in the covered program? (*)
YesNo
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Is this going to be an AMA sanctioned event? (*)
NoYes
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14. Are helmets required? (*)
YesNo
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I UNDERSTAND THAT NATIONAL MOTORSPORTS INC. FOR THE INSURING COMPANY, IS PERMITTED, BUT NOT OBLIGATED, TO SURVEY OUR PROPERTY AND OPERATIONS FOR UNDERWRITING AND/OR LOSS CONTROL PURPOSES AT ANY TIME. I ALSO UNDERSTAND THAT, BY MAKING AN UNDERWRITING AND/OR LOSS CONTROL SURVEY, OR PROVIDING ANY REPORT OF RECOMMENDATIONS, NATIONAL MOTORSPORTS IS NOT UNDERTAKING, ON BEHALF OF, OR FOR OUR BENEFIT (OR OTHERS), TO DETERMINE WHETHER OUR PROPERTY OR OPERATIONS ARE SAFE, OR IN COMPLIANCEWITH ANY STANDARDS, RULES OR REGULATIONS. UNDERWRITING AND/OR LOSS CONTROL SURVEYS ARE FOR THE SOLE PURPOSE OF DETRMINING THE INSURABILITY OF CERTAIN PROPERTY AND OPERATIONS, UNDERWRITING AND SEEKING TO REDUCE CLAIMS AGAINST INSURANCE AND ARE NOT FOR THE BENEFIT OF ANY INSURED OR THIRD PARTY. I UNDERSTAND AND ACKNOWLEDGE THAT WE, THE INSURED, ARE SOLELY RESPONSIBLE FOR THE SAFETY OF OUR PROPERTY AND OPERATIONS, AND WE SHALL NOT REPLY UPON UNDERWRITING AND/OR LOSS CONTROL SURVEYS OR ACTIVITIES TO DETERMINE THE SAFETY OF OUR PROPERTY OR OPERATIONS AND WE SHALL NOT DIMINISH OR FOREGO OUR OWN SAFETY PRACTICES AND PROCEDURES IN RELIANCE UPON ANY NATIONAL MOTORSPORTS SURVEY.

I UNDERSTAND THAT THIS APPLICATION AND ALL INFORMATION SUPPLIED IS PART OF THE APPLICATION PROCESS AND WILL BE RELIED UPON BY THE INSURANCE COMPANY IN DETERMINING WHETHER TO PROVIDE THE INSURANCE COVERAGE HEREIN REQUESTED. ANY MATERIAL MISREPRESENTATION OR FALSE STATEMENT MAY ENTITLE THE INSURANCE COMPANY TO RESCIND THE POLICY, VOIDING ALL INSURANCE COVERAGE. I HEREBY WARRANT, REPRESENT AND CONFIRM THAT I HAVE READ ALL OF THE QUESTIONS AND ANSWERS ON THIS APPLICATION AND THAT, TO THE BEST OF MY KNOWLEDGE, ALL INFORMATION PROVIDED IN THIS APPLICATION IS COMPLETE, TRUE AND CORRECT.

IT IS UNDERSTOOD AND AGREED THAT NO INSURANCE IS IN EFFECT UNTIL THIS APPLICATION IS ACCEPTED BY THE COMPANY OR COMPANIES IN WRITING.

THIS APPLICATION SHALL BE ATTACHED TO AND BECOME A PART OF ANY POLICY, SHOULD A POLICY BE ISSUED AS A RESULT OF THIS APPLICATION. THE APPLICATION SHALL BE DEEMED A SCHEDULE TO SUCH POLICY, BUT THE SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER UNLESS AND UNTIL A POLICY OF INSURANCE IS ISSUED IN RESPONSE TO THIS APPLICATION.

Name of Signature (*)

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Signature Date (*)


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By signing above, I authorize National Motorsports, in accordance with provincial regulations, to obtain, on my behalf, detailed five-year loss runs from any and all companies from which I have obtained insurance.





NOTICE: Insurance cannot be bound without confirmation of payment from an invoice. This application will not secure coverage for your event. Coverage is only bound when we obtain payment and you receive a certificate.