Request for Insurance for Sanctioned Events - ACA | Canoe - Kayak - SUP - Raft

Request for Insurance for Sanctioned Events

Paddle America Clubs and Affiliate Organizations:

The ACA will issue a certificate of insurance, evidencing coverage to all Paddle America Clubs and Affiliate Organizations and their event organizers in good membership standing for their events.

The ACA's insurance may cover third parties associated with an event (ex. sponsors, land owners, etc.) by naming them as "additional insureds." Complete the form below to submit a request for a certificate of insurance for your event. Only one event per form may be submitted. You will be prompted to enter additional insured information on the next page and will be able to pay the appropriate fees online when you are done.

Certificate requests made less than ten (10) days prior to the date needed will incur an additional rush fee of $25.00. All fields on this form must be completed. Please answer n/a when not applicable.

Services	Affiliate Organization Fees	Paddle America Club Fees
Sanctioning Fee*	$25.00	Free
Rush Fee*	$25.00	$25.00
Additional Insured (per each)*	$20.00	$20.00

*All Fees are non-refundable

If you need additional information, contact the ACA Insurance Coordinator.

Event Organizer Information
Organization *Paddle America Club, Affiliate Organization or Division Name
Address Line 1 *
Address Line 2
City *		State *
Zip *		Phone *
Email Address *
Web Address
The Event Organizer must be a current member of the ACA. Call (540)907-4460 ext 103 to verify membership if necessary. Certificates will be sent to the e-mail address provided below.
Contact Name *Primary point of contact for the event or insurance program
Contact ACA Number *		Contact Phone *
Contact E-Mail Address *
Event Information
Rivers rated Class III and above require a detailed Safety Plan as per ACA Risk Management Guidelines. Events on Class III+ water must submit all necessary paperwork at least 14 days prior to the event.
Addit'l Insured Certificates *Do you require any Additional Insured certificates	Yes No	If Yes, How Many?
Estimated # of participants *		Date Certificate is needed *When do you need the actual Insurance Certificate by - MM/DD/YYYY
Event Name *
Begin Date *MM/DD/YYYY		End Date *MM/DD/YYYY
Venue *River, Lake, Park, Pool, etc.
River Classification *	N/A Class I Class II Class III Class IV Class V	Nearest City, ST *
Minimum Water Flow LevelIf your event is held on whitewater, please indicate the minimum water flow level (in feet or CFS) to host the event.		Maximum Water Flow LevelIf your event is held on whitewater, please indicate the maximum water flow level (in feet or CFS) to host the event.
Event Description *Provide a brief description of the event
Event Checklist & Planning
The following pre-event checklist is intended to demonstrate that the event organizers have properly planned this event in order to prevent accidents and handle emergencies if (when) they occur and will assist in the preparation of an appropriate emergency plan.
Staff & Volunteers *How many staff & volunteers do you plan to involve?		Event Safety Coordinator *Who is the activity/event Safety Coordinator?
Emergency Procedures *Who is responsible for planning/leading emergency procedures?		Site Inspection *Who is responsible for inspecting the activity event site for possible hazards?
Coordination *Who is responsible for coordinating officials and ensuring that all rules are followed?		Relaying Information *Who is responsible for relaying activity/event rules and possible hazards to participants?
Medical Emergencies *What are your procedures for medical emergencies?
Emergency Vehicles *Are there emergency vehicles on site?	Yes No	ExplainAdditional Info regarding emergency vehicles on-site...
Evacuation Plan *Briefly, what are your plans for emergency evacuation of spectators and/or participants?
How many spectators *Estimated number of spectators attending
Safety Boats *Are there safety boats?	Yes No	If so, how many?Regarding Safety boats
How are safety boats used?If so, how will they be used?
Shelter *What provisions are being made for shelter from sun, heat or cold?
Facilities *What provisions are being made for drinking water and toilet facilities?
Spectator Management *How will you manage spectators?
Social Media Promotion Plan -
Please outline how you will acknowledge the ACA for this event, (ie., in press releases; on your website or social media sites; incorporating the ACA logo into advertisements and publications, signage, etc.).
Social Media Promotion Plan *
NotesIf you need to clarify anything, you can do so here. Including but not limited to letting us know if you need to pay with a check rather than online.
Agreement with Submission:
As the ACA Member/Event Organizer in charge of this event, acting as an agent of the Organization detailed above, I hereby agree that the event will be conducted in accordance with all ACA requirements, Risk Management, and all other rules, guidelines, and conditions established by the ACA. I have read and fully understand the sanctioning requirements established by the ACA, I have personally inspected the event site(s) and I attest to the fact that such site(s) are appropriate for use in this event and free of undue hazards.
Signature *By typing your name in this filed you are agreeing to follow all of the ACA Risk Management Criteria

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ACA Mission

Founded in 1880, The American Canoe Association (ACA) is a national nonprofit organization serving the broader paddling public by providing education related to all aspects of paddling; stewardship support to help protect paddling environments; and sanctioning of programs and events to promote paddlesport competition, exploration and recreation.