Contact Us:
800-874-1738

Rider School Program

Rider School

Rider School Program Quote Application


Applicant Information
Name of Insured (as it should appear on policy):
D.B.A. Name:
Primary Contact (full name):
Email Address:
Contact is:
Physical Address:
Mailing address (if applicable):
City, State, Zip:
Phone number:
Fax number:
Nature of Business:
Business is:
In what state is the organization Headquartered/chartered?
When do you need the coverage to begin?
How did you hear about us?
Coverage Information
Type of coverage and limits desired:
General Liability
    Primary $1,000,000 Each Occurrence/$2,000,000 aggregate
    Excess Medical Payments - $10,000 each student
Inland Marine
    Unit Physical Damage - $250 Ded.  Number of Units:  Total Value of Units:
    Miscellaneous Equipment
    Domino Coverage
    Third Party Testing
    Physical Damage for Instructor's bikes
        ($500 deductible, $50 per bike premium)
Underwriting Information
How many losses in the last 3 years?
Are all applicants required to sign a waiver? Yes No
If a participant is a minor, are the parents or legal guardian required to sign a waiver? Yes No
Estimate the number of students for the coming year: BRC ERC 2UP
3rd Party Testing
Are there formal medical procedures for injured students? Yes No
Are written reports required for all accidents? Yes No
Do you have motorcycles on the loan program? Yes No
Where are your bikes stored?
Please describe your security precautions:
Additional Information
Please include any additional information that may help us process your request.