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

Insurance Request Form

Event Organizer Information
Organization Name *Name of Paddle America Club or Affiliate Organization.
Address Line 1 *
City *		State *
Zip *		Phone *
Email *		Organization Website
The Event Organizer must be a current member of the ACA. To verify, please call the ACA Office at 540-907-4460 ext 112. Certificates of insurance (COI) will be sent to the event organizer.
Event Organizer Name *Primary point of contact for the event or organization.		Event Organizer Email *
Event Organizer ACA Number *		Event Organizer Phone *
Event Information
Events that occur on whitewater rivers rated Class III and above must be submitted at least 10 days prior to the event.
Event Name *
Event Description *
Event Start Date *MM/DD/YYYY		Event End Date *MM/DD/YYYY
Estimated # of Spectators		Venue / Waterway *River, Lake, Pool, etc.
Nearest City and State *Please indicate the nearest city and state to your chosen venue / waterway.		This event is primarily (please choose one): *	Education/Instruction Stewardship Competition Club/Social Other
River Classification *If this event is to occur on a moving water river, please indicate the highest level of rapid(s) classification.	N/A Class I Class II Class III Class IV Class V	Minimum Water Flow LevelIf this event is to occur on a moving water river, please indicate the minimum water flow level (in feet or CFS) required to safely host the event.
Maximum Water Flow LevelIf this event is to occur on a moving water river, please indicate the maximum water flow level (in feet or CFS) required to safely host the event.
Event Safety Plan
As part of responsible event planning and preparedness, outline the following risk management and safety details as they pertain to the prevention of accidents and emergency response.
Event Safety Coordinator *Who is the activity/event safety coordinator?		Staff & Volunteers *How many staff & volunteers will be involved in the event?
Site Inspection *Who is responsible for inspecting the event site for possible hazards?		Relaying Information *Who is responsible for relaying activity/event rules and possible hazards to participants?
Medical Emergencies *What are the event procedures for medical emergencies?
Emergency Vehicles *Will there be emergency vehicles on site?	Yes No	Emergency Vehicle InformationProvide additional information regarding emergency vehicles on-site.
Evacuation Plan *What are event procedures for emergency evacuation of participants and spectators?
Safety Boats *Will this event utilize safety boats?	Yes No	How Many Safety Boats?
How will safety boats be utilized?
Shelter *What provisions are being made for shelter from heat, cold, inclement weather, etc?
Facilities *What provisions are being made for drinking water and toilet facilities?
Spectator ManagementHow will the event manage spectators?
Additional Insured Certificates *Do you require any "additional insured" certificates of insurance (COIs)?	Yes No	If Yes, How Many?
Date Certificate Is Needed *When do you need the certificate of insurance (COI)?		Custom Online SmartWaiver Link? *Would you like a custom SmartWaiver link for this specific event?	Yes No
Custom Waiver Link - Event Managers' Name and Email Address(es)If you requested a custom online SmartWaiver link, please list the first name, last name, and email address of the person(s) responsible for managing the online waivers. Maximum of 5.
Additional InformationIf you have additional information that you'd like to include in your insurance request, please upload here.
Post to ACA Online Calendar? *Would you like this event to be posted on the ACA's online Community Calendar for the public to see/inquire about your event?	Yes No
Signature *By typing your name in this field you are agreeing to follow all of the ACA Risk Management Criteria

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