NSSA/NSCA Instructor
Liability Application

 
1. Instructor's Name:
   
2. Business Name:
   
3. Mailing Address:
   
4. City: State: Zip:
   
5. Daytime Phone: Evening Phone: Fax:
   
6. Email Address: Website:
   
7. Member of: NSSA NSCA | Member #:
   
8. Level of Certification: I II III Master Recreational Scholastic
Date Certified: mm-dd-yyyy
   
9. Number of Years Teaching: Average Number of Students Per Ccourse:
   
10. Estimated Number of Courses Taught: | Do You Conduct Handgun Classes? Yes No
   
  Additional Operations (If you answer yes to any of the following please contact us for a quote)
   
11. Do you conduct courses on layout and/or design? Yes No | If yes, provide gross annual receipts:
   
12. Do you have your own permanent facility you use for instruction? Yes No
   
  If yes, do you have any of the following:
   
  Rifle/Pistol Ranges: Yes No | Sale of New/Used Firearms: Yes No
   
  Fishing: Yes No | Archery: Yes No
   
  Clubhouse or grounds you rent out to others? Yes No
   
13. Have you published any instructional books, manuals, or videos? Yes No
   
  If yes, please describe below:
 
   
 

Certificates of Insurance

(Proof of Insurance Only or Additional Insured Land Owners)
Some of the facilities where you instruct may require you to list them as an additional insured or provide them
with proof of insurance.

Please complete the following to add these facilities at no additional premium.
Please note: All informationmust be provided. (If you have more than 3 certificate holders please attach a separate sheet to this form)
   
 
1) Entity Name: Please check one:
   
Mailing Address: Proof of coverage only
   
City State Zip Additional_Insured_Land_Owner
   
 
2) Entity Name: Please check one:
   
Mailing Address: Proof of coverage only
   
City State Zip Additional Insured Land Owner
   
 
3) Entity Name: Please check one:
   
Mailing Address: Proof of coverage only
   
City State Zip Additional Insured Land Owner
   
   
 

Operations

Gross Annual Revenues: (For course layout and design – Call for a quote)

  Instruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $  
       
  Shooting Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $  
       
  Other Revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $  
       
  Total Revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $  

 

 

Premium Calculation

  A. Gross Receipts up to $20,000 - Minimum premium: $300  
       
  B. Gross Receipts over $20,000; $ /1,000 x $7:  
       
  Total of A & B above = Total Annual Premium:  
       

 

 

Terms

I understand that this application and all information supplied is part of the application process and relied upon by the insurance company in determining whether to provide the insurance coverage herein requested and that the application will become a part of any contract of insurance entered into. Any material misrepresentation or false statement may entitle the insurance company to rescind the policy, voiding all insurance coverage. I hereby warrant, represent and confirm that I have read all of the questions and answers on this application and that to the best of my knowledge, all information provided in this application is complete, true and correct. I further warrant that I have made or will make the necessary maintenance inspections and that all necessary repairs have been made to ensure that my property and operations are and will remain in compliance with any underwriting criteria furnished me.

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

   
  Signature: Date: mm-dd-yyyy
   
 

Method of Payment

   
  Check Number: Made payable to: Sportsman's Insurance Agency, Inc.

Credit Card: Discover Master Card Visa American Express

Card Number: Security code: Expiration Date: mm-yyyy

Credit Card Authorization Signature:
   
 
   
   
 

Sportsman's Insurance Agency, Inc.
1364 N. US 1, Suite 503
Ormond Beach, Florida 32174
800-925-7767
Fax 386-677-3292
Email: chuck@siai.net
Website: www.siai.net