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270-467-8848
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About
Products
Collector Vehicle Insurance
HPDE Insurance
Personal Umbrella Policy
Car Club Liability Quote Request
NCM Choice
Services
Claims
Update Your Policy
Frequently Asked Questions
Blog
Contact
Contact Us
Become an Agent
270-467-8848
info@ncminsurance.com
GET A QUOTE
Get a Quote
Contact Us
About
Products
Collector Vehicle Insurance
HPDE
Personal Umbrella Policy
Car Club Liability Quote Request
NCM Choice
Customer Service
Claims
Update Your Policy
Frequently Asked Questions
Blog
Become and Agent
Car Club Liability Quote Request
Car Club Liability Form
Step
1
of
3
33%
Name of Club
(Required)
Name of Club
Club Mailing Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Club Website
Phone
(Required)
Please enter the best # to reach an officer of the club.
Club Officer Email
(Required)
Club Contact Name
(Required)
First and Last Name
Liability Limits
Limits of Liability
(Required)
$1,000,000 Limits of Liability / $3,000,000 General Aggregate
$2,000,000 Limits of Liability / $4,000,000 General Aggregate
Club Information
Year Club Established
(Required)
Type of Entity
(Required)
For Profit
Not-For-Profit
Other
# of Individual Members including Individuals in Family Membership
(Required)
# of Active Members
(Required)
Desired Effective Date
(Required)
MM slash DD slash YYYY
Does your club currently have insurance?
(Required)
SELECT ONE
Yes
No
Who is your current car club liability carrier?
Please List Date, Name of Event and Location of Club Related Events below.
Example: 10/21/2022 - NCM Bash - Bowling Green, KY
This club follows and adheres to written established by-laws.
(Required)
Yes
No
Waiver/release of liability is signed by participants for all activities including parent/legal guardian of minors.
(Required)
Yes
No
If yes, releases are archived for a minimum of 5 years.
(Required)
Yes
No
N/A
If you own, lease or rent a location, please explain.
Club Events
This policy provides coverage for specialty clubs and operations that are part of the club such as: business or social meetings, breakfast/lunch/dinner meetings including host liquor liability, sponsored excursions (weekend cruising event, overnight excursion, organized attendance to public function such as sporting events, cultural events, tours, etc.), holiday socials or picnics (members and guests, not a fund raiser), parade participation other than sponsorship, caravans, car rallies, cruising, fund raisers (own or for charity) and public events with less than 1,000 participants/spectators.
Untitled
Name of Event
Date of Event
Event Description
# of Participants NOT club members
Location of Event
Total Receipts
Actions
Edit
Delete
There are no
Entries.
Add Entry
Maximum number of entries reached.
Does the club participate, sponsor or host in any of the following activities: racing or timed events, speed contests, rallies, gymkhanas, autocross, or other performance driving or racing activities?
No
Yes, explain below
Other
Does the club rent out their owned facilities?
Yes, please indicated amount earned from rentals below in the "Other" section
No
Other
Is Liquor Liability coverage desired?
Yes
No
Any events with more than 1,000 people in attendance?
Yes
No
Does the club charge for alcohol at any event? If yes, select other and yes and enter the amount earned.
Yes
No
Other
Has the club ever been cancelled or refused coverage in the last 5 years? (Not applicable in Mussouri)
Yes
No
If yes, please explain:
Untitled
Current/Past Carriers
Effective Dates
Premium
# of Claims
Amount Paid in Claims
Description of Losses
Actions
Edit
Delete
There are no
Entries.
Add Entry
Maximum number of entries reached.
Fair Credit Report Act Notice:
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
Fraud Warning:
Fraud Warning: 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 [NY: SUBSTANTIAL] CIVIL PENALTIES. (NOT APPLICABLE IN CO, DC, FL, HI, MA, NE, OH, OK, OR, VT OR WA) (INSURANCE BENEFITS MAY ALSO BE DENIED IN LA, ME, TN, AND VA.)
STATE FRAUD STATEMENTS
THIS NOTICE IS PART OF YOUR APPLICATION:
APPLICABLE IN COLORADO
IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OF AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APPLICABLE IN THE DISTRICT OF COLUMBIA
WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
APPLICABLE IN FLORIDA
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
APPLICABLE IN HAWAII
FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH.
APPLICABLE IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT
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, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN OHIO
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTION STATEMENT IS GUILTY OF INSURANCE FRAUD.
APPLICABLE IN OKLAHOMA
WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.
APPLICABLE IN WASHINGTON
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.
Is your club a registered 501(c)3 entity?
(Required)
(Select One)
Yes
No
Are you interested in Directors & Officers Coverage?
(Required)
(Select One)
Yes
No
CAPTCHA
Consent
I accept the above
By submitting this form you are agreeing that the information entered above is accurate and that you accept the information outlined above.
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CA License #0G81393
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