Insurance Request Form

Organization Name(Required)

Organization Street Address(Required)

Organization City, State, Zip Code(Required)

Event Organizer Information

Organizer Name(Required)

Organizer Email(Required)

Event Information

Event Name(Required)

Event Start Date(Required)

Event End Date(Required)

Event Description(Required)

Event Venue/Waterway River Classification

If this event is to occur on a moving water river, please indicate the highest level of rapid(s) classification.

Minimum-Maximum Water Flow Levels

If 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.

Event Venue/Waterway(Required)

This event is primarily:

Education/Instruction

Stewardship

Competition

Club/Social

Other

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 Name(Required)

Event Safety Coordinator Email(Required)

Number of Staff and Volunteers(Required)

How many staff & volunteers will be involved in the event?

Person Responsible for Site Inspection(Required)

Who is responsible for inspecting the event site for possible hazards?

Person Responsible for Relaying Information(Required)

Who is responsible for relaying activity/event rules and possible hazards to participants?

Medical Emergencies(Required)

What are the event procedures for medical emergencies?

Will There Be Emergency Vehicles On SIte?(Required)

Emergency Vehicle Information

Evacuation Plan(Required)

What are event procedures for emergency evacuation of participants and spectators?

Will This Event Utilize Safety Boats?(Required)

If so, how many safety boats?

Shelter(Required)

What provisions are being made for shelter from heat, cold, inclement weather, etc.?

Facilities(Required)

What provisions are being made for drinking water and toilet facilities?

Spectator Management(Required)

How will the event manage spectators?

Additional Insured Certificates Needed(Required)

Yes

If Yes, How Many?

Date Certificate(s) Are Needed(Required)

Post to Event on ACA's Online Event Calendar?(Required)

Yes

Additional Information (Optional)

Max. file size: 40 MB.

Signature(Required)

By typing your name in this field you are agreeing to follow all of the ACA Risk Management Criteria.