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Home > Board Retailers Assocation Lessons Form Page

Board Retailers Assocation Lessons Form Page

Are you a member of the Board Retailers Association?
- Yes
- No
Do you have any other memberships?
- Yes
- No
If so, please list:
Lessons?
- Yes
- No
Contests?
- Yes
- No
If so, please advise the type of contests and number of participants:
Does your business offer:
- Lessons Only
- Surf Shop & Offering Lessons
Business Description
Legal Company Name
Your Name
First Last
Mailing Address
Street Address Address Line 2 City State ZIP Code
County
Contact Phone Number
Contact Email Address
Contact Fax Number
Contact Mobile Phone Number
Lessons
Are you looking for coverage for select type of lessons given?
- Yes
- No
Type of lesson given:
Lesson type age breakdown 18 and under (number of participants):
Lesson type age breakdown 19 and over (number of participants):
How many locations will you be giving lessons at?
Location One Address
Street Address Address Line 2 City State ZIP Code
Location Two Address
Street Address Address Line 2 City State ZIP Code
Location Three Address
Street Address Address Line 2 City State ZIP Code
Location Four Address
Street Address Address Line 2 City State ZIP Code
How many entities are requesting a certificate of insurance?
Entity One Name
Entity One Address
Street Address Address Line 2 City State ZIP Code
Entity Two Name
Entity Two Address
Street Address Address Line 2 City State ZIP Code
Entity Three Name
Entity Three Address
Street Address Address Line 2 City State ZIP Code
Entity Four Name
Entity Four Address
Street Address Address Line 2 City State ZIP Code
Estimate the total number of students you will instruct over the next 12 months:
Estimate the average number of instruction hours per student:
Total percentage of students given lessons to who are 18 and under:
Total percentage of students given lessons to who are 19 and over:
Anticipated gross receipts from instruction this coming year:
Please indicate the type of waters you anticipate to instruct in:
Please describe your teaching location:
Do you use MOTORIZED watercraft in your instruction?
- Yes
- No
If so, please describe the watercraft used for instruction (Year, Make, Model, Horsepower):
Are there lifeguards at your instruction site?
- Yes
- No
Were you ever trained as a lifeguard?
- Yes
- No
Are you a trained water safety instructor?
- Yes
- No
Are you trained in CPR?
- Yes
- No
Are you trained in first aid?
- Yes
- No
Percentage of students age 18 and under:
Are PFD worn by students during instruction?
- Yes
- No
Is the swimming ability of students verified prior to initiating instruction?
- Yes
- No
Do you require a waiver of liability prior to instruction?
- Yes
- No
Do you require a waiver of liability prior to instruction for your state?
- Yes
- No
Surfboard and Paddleboard Instructor:
Are your instructors NSSIA CERTIFIED?
- Yes
- No
Number of years of teaching experience:
Other certification:
Are your Kiteboard instructors certified?
- Yes
- No
Number of years of teaching experience:
Other certification:
Years you have been in business under this name:
Ratio of instructors to students:
Any suits or claims in the past three years?
- Yes
- No
If so, please explain:
Have you ever had a claim?
- Yes
- No
If so, how long ago was the claim, and provide explanation:
Do you currently have insurance coverage?
- Yes
- No
Insurance Company Name
Expiring Premium
Renewal Date
MM slash DD slash YYYY
Years you have been insured with this company:
Do you rent equipment?
- Yes
- No
If yes, what are your gross rental revenues?
Does the renter sign a waiver of liability form?
- Yes
- No
I confirm all information above is accurate and correct
Please Initial
Email
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Contact

Intermarket Insurance Agency

205 East Main St
Suite 3-4
Huntington, New York 11743

Phone: (631) 421-2424

Fax: (631) 421-2004

Mon-Thu: 9:00am-5:00pm
Fri: 8:30am-4:30pm
Sat-Sun: Closed

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