L i a b i l i t y   I n s u r a n c e   f o r   t h e   W h i t e w a t e r R a f t i n g   a n d   C a n o e   L i v e r y   I n d u s t r i e s

Name:
Title:
Phone:
Fax:
E-mail Address:
Name of Company:
Address:
Member AO, PPA, or Other Organization?
Rivers Rafted:
Estimated Participants:
Any Food/Liquor Service Changes?	Yes     No
Any Additions or Deletions in Activities?	Yes     No     If Yes, Please Describe:
Any Other Changes in Operations?	Yes     No     If Yes, Please Describe:
Estimated Total Annual Gross  Receipts from all operations:	$
Gross Receipts from Rentals  of Canoes, Kayaks, Rafts:	$

Other Activities			Gross Sales
Location	Gift Shop	Campground	Restaurant	Motel	Bike Rentals	Other
	$	$	$  (food)   $  (liquor)	$	$	$
	$	$	$  (food)   $  (liquor)	$	$	$
	$	$	$  (food)   $  (liquor)	$	$	$
	$	$	$  (food)   $  (liquor)	$	$	$

Gift Shop - Include tee-shirts, souvenirs, souvenir photos, etc.

Restaurant - Include snack bar, restaurant, etc.

Motel - Include hotel, motel, cabins, Bed & Breakfast, etc.

Other - Identify by activity such as cross-country skiing, etc.

Limits Desired:	$500,000/$1,000,000 $1,000,000/$2,000,000 $2,000,000/$2,000,000
Certificate Holders (include fax number  if you desire same day transmittal):
Additional Insureds (include fax number  if you desire same day transmittal):