PAC Certiﬁcate Request Form
The ACA will issue a general certiﬁcate of insurance, free activity/event (ex: sponsors, landowners, etc.) by naming them
of charge, to all PACs in good standing who are insuring their as “additional insureds.” If a third party demands an “Additional
scheduled activities/events. Insured” listing, the PAC should ﬁll out the appropriate section
PACs may require certiﬁcates of insurance for a speciﬁc of the “Certiﬁcate Request Form” and submit it to the ACA along
activity/event. Certiﬁcates of insurance generated for this type of with a fee of $20 for each requested additional insured. Requests
request will also be provided free of charge. PACs should use the to list additional insured(s) less than (10) days prior to the date
“Certiﬁcate Request Form” to obtain a certiﬁcate of insurance. needed will incur an additional rush fee of $25.
ACAʼs insurance may cover third parties associated with an
General certiﬁcate of insurance Free
Certiﬁcate of insurance request for Free
Request to list Additional Insured $20 (per additional insured plus
on certiﬁcate of insurance an additional $25 rush fee for
certiﬁcates requested within 10
days of activity)
This certiﬁcate is for (check one):
® Speciﬁc Activity/Date (* required information)
Estimated # of Particpants*:
® General Activity (certiﬁcate will cover entire calendar year of PAC paddlesport related activities)
Date Certiﬁcate of Insurance needed:
PAC Representative Name:
PAC Mailing Address:
City: State: Zip:
PAC Email Address:
PAC Web Address:
If you request a General certiﬁcate, remember to notify the ACA of all PAC activities in order to be considered insured.
Failure to inform the ACA may jeopardize insurance coverage. See the “2006 PAC Manual” for notiﬁcation procedures.
Provide brief description of the speciﬁc PAC activity or general PAC activities*:
**Please list any additional insureds that need to be listed on the PACʼs certiﬁcate of insurance. If you have muliple Additional
Insureds please attach a separate sheet. You will need to include the information below for each Additional Insured.
Complete Name of Additional Insured:
Contact Person for Additional Insured:
Additional Insured Mailing Address:
Additional Insured Number & Fax:
Additional Insured Email Address:
Please outline the relationship of the additional insured to the activity or PAC (ex: sponsor, landowner, etc.):
Please specify below Additional Insured wording if name on Certiﬁcate is different than name above, or attach a copy of
their written request or instructions. American Specialty must review and approve request.
As concerns the Additional Insured above, has the PAC entered into any agreement, contract, or permit that contains As-
sumption of Liability, Indemniﬁcation, or Hold Harmless Language? Y or N (Circle One)
If “yes”, please forward a copy of the document with this request.
As the ACA member in charge of this activity/event, acting as an agent of the Paddle America Club, I hereby
agree that the activity/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 I fully understand the Paddle
America Club Agreement and all sanctioning requirements established by the ACA, I have personally inspected
the activity/event site(s) and I attest to the fact that such site(s) are appropriate for use in this activity/event and
free of undue hazards.
ACA Member Number:
Payment for Additional Insureds
Make checks payable to the “American Canoe Association”
® Visa ® Mastercard ® AmEx ® Discover Exp. Date:
Name on Card: