Canadian Summer Hockey
AAA, AA, 3 on 3
Application for Team or League Insurance
Cert No. 0
No. Teams 0
Association or Team Name:
City: Province: PC:
Manager Name: Desired Effective Date:
Contact for Insurance Questions:
Email: Phone: Fax:
Number of Teams to be Included in this insurance:
Number of Contact Teams: Number of Non-contact Teams:
Total Number of Players on all Teams: Player Birth Years:
Total Number of Male Players: Female:
Any US Players?: (If yes, please attach proof of travel sports medical insurance)
Total Number of Coaches:
Please Indicate tournaments you are attending (this list does not limit your play):
Do you intend to play in any US tournaments? When? N/A
Please Note: This is an application ONLY. It does not constiture an insurance policy. Insurance shall become effective only on
issuance of a policy or a written binder specifically authorized by the company or agency.
Applicants Signature: Position:
Applicants Name (Please Print): Date:
DECLARATION To the best of my knowledge and belief all statements made in this Application for Insurance are true. Signing of this document
by clicking below does not bind the Applicant to complete the insurance, but it is agreed that this Application shall be the basis of the contract,
should a policy be issued. I Accept
Are you an Ontario Resident? (Enter a Y for yes or a N for no)
Credit Card Number: Expiry:
Payment Method: VISA MC
Office Use Only
Once payment has been made,you will receive a valid certificate number.
KAI Fee: Certificate Number
Canadian Summer Hockey
AAA, AA, 3 on 3
No More Membership or Registration Fees. , we believe that it’s all about playing hockey. All you have to do is get your
team together and apply.
US Players. US Players are welcome to play on Canadian Teams. HOWEVER ALL USA PLAYERS MUST CARRY
THEIR OWN VISITORS TO CANADA SPORTS ACCIDENT OUT OF COUNTRY MEDICAL AS THEY ARE EXCLUDED
FROM OUR ACCIDENT POLICY.
US Tournaments. Canadian teams are not restricted from playing in US tournaments, however ALL CANADIAN TEAMS
TRAVELLING TO THE US MUST CARRY THEIR OWN SPORTS TRAVEL MEDICAL
Rates for Out of Country Sports Accident Medical available for both Canadian and USA players.
Payment. All COMPLETED AND SIGNED application forms must be received prior to the effective date of your first
tournament. Payment must accompany the application in the form of a credit card number or cheque. Insurance
Certificates will be issued once p
Policy Includes Lloyds of London $2,000,000 Liability & AXA /CITADEL Sports Accident Coverage
Please call our toll free Number for Team Rates
Group Rates Available
If you have any questions at all about our program, please contact Ted Dolinski at 306-569-2288.
The bottom line. We want to make this as easy as possible for you. Just go play.
***NO REGISTRATION OR MEMBERSHIP FEES REQUIRED***
Why Liability Insurance?
Because no matter how careful you are, accidents happen. And you can be sued by anyone who claims injury or damages
Who is Insured?
All members of your organization, including players, executives, managers, coaches, trainers, officials, employees and volunteers
Sanctioned or authorized events & fundraisers, including related training authorized by you.
Host Liquor Liability Coverage available upon request.
General Liability Insurance
The policy will pay those sums that the insured becomes legally obligated to pay as compensatory damages because of bodily
Limit - $2,000,000 Aggregate
Including the following extensions:
- Premises, Property and Operations
- Products and Completed Operations
- Blanket Contractual
- Personal Injury (libel and slander)
- Employees as Additional Insured
- Cross Liability
- Non-Owned Automobile - $1,000,000
- Tenants Legal Liability - $250,000
THIS IS AN ANNUAL POLICY – JANUARY 1, 2010 TO JANUARY 1, 2011
Includes tryouts, practices, all tournaments your team may attend in Canada or the USA during the entire year, you do not need a
A reimbursement deductible of $1,000 applies to bodily injury, property damage and legal expenses.
Special Policy Features:
Canadian teams can have US players on their roster provided US players have Visitors to Canada sports medical coverage in
Canadian teams playing in US tournaments are covered for liability. ALL players must carry out of country sports medical
If you wish to purchase out of country sports medical coverage, Please call out toll free number and we will forward an application
US Players playing in Canada Please call for Rates
Canadian Players playing in US - $3.75 per person per day - $5,000,000 benefit limit.
Coverage must be purchased prior to departure.
NO MORE CHARGE FOR HOSTING TOURNAMENTS
We will provide coverage for your hosted tournament(s) including volunteers, coordinators, etc.
You must ensure that every team that participates in your tournament provides proof of liability coverage prior to playing
TOLL FREE 1-888-818-5032
firstname.lastname@example.org or email@example.com
Policy Period JANUARY1,2010 JANUARY 1,2011
Accident/Medical Coverage Summary:
Provided by Axa Citadel.
Who is it for?
This policy is intended to provide protection for players, managers, coaches, administrators and officials during
Why is this coverage right for me and for my team?
No shadow of worry should ever spoil a beautiful day on the field, so The Citadel has developed a
$10,000 principal sum (higher amounts are available) is payable in the event of loss of life resulting from injury.
Up to 200 percent of the principal sum is payable in the event of the loss of use of hands, arms or legs,
Up to $10,000 is payable for the cost of prescription drugs, ambulance fees, hospital charges in excess of
Up to $1,000 for Body Contact Sports or $5,000 for Non-Body Contact Sports is payable for dental treatment
Up to $1,000 is payable if a bone or bones are fractured (including chip and linear fractures).
Transportation from the scene of the accident to the nearest hospital or doctor’s office, following an injury, is
If special occupational training is required as the result of a sports accident, up to $5,000 is available to cover
Tutorial fees* of up to $2,000 are covered if required during post-accident confinement. (* except in Quebec)
...you might wish to consider at additional cost.
Permanent Total Disability
As much as $10,000 is payable for a person between the ages of 18 and 70 who becomes totally disabled as a
Dentures or Bridgework
Should repair or replacement of dentures or bridgework be necessary as a result of a sports accident as much
Eyeglasses or Contact Lenses
If eyeglasses or contact lenses must be replaced as a result of a sports accident and when neither were
As much as $150 per round trip (maximum five trips per policy term) for transportation and up to $50 per day
Exclusions To The Plan:
Any loss caused or contributed to by suicide or intentionally self-inflicted injury.
War, whether declared or not
Active full-time, part-time or temporary service in the armed forces of any country
Any of the hazards of aviation, except while riding as a passenger in any aircraft which is not owned, operated, leased or chartered by, or on behalf of, the policyholder or the insured person.
Participating in any speed contest or racing.
Expenses incurred for eyeglasses/contact lenses, or prescriptions therefor.
The purchase, repair or replacement of artificial teeth, dentures, fillings or crowns.
Sickness or disease.
Experimental drugs or medical treatments.
Medical services rendered by physicians, surgeons, nurses, physiotherapists, certified athletic sports therapists and chiropractors employed by or engaged by the Policyholder.
Expenses incurred by a person who is not covered under any Federal or Provincial Hospital or Medical Plan.
Expenses incurred outside of Canada by a person who is non-Canadian resident
Any of the above losses, costs, expenses or treatments must be incurred w ithin 52 w eeks of the date of the accident.
Accidents and expenses must be incurred in Canada.
There is no limit to the number of accidents covered - per insured person or team.
This policy is subject to and does not contravene any Federal or Provincial statutory requirements w ith respect to Hospital or Medical Plans. Reimbursement of medical and dental expenses w ill be
YOU DO NOT HAVE TO BELONG TO ANY ASSOCIATION.
***NO REGISTRATION OR MEMBERSHIP FEES REQUIRED***
Knight Archer Insurance Statement
512 Victoria Avenue East
Regina, Saskatchewan Date 3/19/2009
(306)569-2288 Cert. No. 0
No. of teams 0 $ -
No. of players 0 $ -
No. of coaches 0 $ -
Ontario PST 8% $ -
Knight Archer Insurance Fee $ -
Notes: Total premium
WAIVER AND RELEASE OF LIABILITY
In consideration of being allowed to participate in any way in CANADIAN SUMMER HOCKEY, related events and activities, the undersigned acknowledges, appreciates, and agrees
The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and
personal discipline may reduce this risk, the risk of serious injury does exist; and,
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for
my participation; and,
I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual significant hazard during my presence or
participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,
I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS CANADIAN SUMMER HOCKEY their officers, officials,
agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (“Releasees”),
WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
FOR PARTICIPANTS OF MINORITY AGE, PLEASE SIGN ON PAGE 2
PARTICIPANT DATE WITNESSED BY
FOR PARTICIPANTS OF MINORITY AGE
(UNDER AGE 18 AT TIME OF REGISTRATION)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my
heirs, assigns, and next of kin, I release and agree to indemnify the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as
MINOR’S NAME GUARDIAN’S DATE WITNESSED BY
m/d/yyyy COACH MGR