Supplemental Accident Insurance Application FY20

Trout Unlimited Inc. Request for Chapter/ Council Accident Insurance

The chapter/council premium for an SAI policy will be $115 for $25,000 in coverage (Plan 1), or $155 for $50,000 in coverage (Plan 2). This policy term runs from April 1st through March 31st of the following calendar year. If you purchase your policy after April 1st it will be active from the date payment for the policy is received through the end of the fiscal year (March 31st).

A ‘council’ will be treated as a ‘chapter’ for activities it conducts and originates. It will not include ever chapter under its jurisdiction.

Your completed application will be effective on the date the signed application and check is received at the TU National Office in Arlington. For your convenience, a copy of your policy will be uploaded into the Electronic Documents Storage in the Leaders Only Tools. In the memo line of the check, please write “INSURANCE”.  All payments must be made out to ‘Trout Unlimited Inc.’ Please return your application and check to:

Trout Unlimited, Inc.,

ATTN: Nick Halle

1700 N Moore St.

Suite 2005

Arlington, VA 22209

Policy cover is: 

Accident medical:  $25,000 or $50,000 per participant per accident

Accident dental: included in above limit

Deductible per: None

Benefit period: 26 weeks

Plan coverage: Full excess

Accidental death: $15,000

Accidental dismemberment:  $25,000 or $50,000

Accidental death & dismemberment aggregate: $500,000 per accident

Who is covered: All registered active members of the participating TU chapter/ council as well as guests, and campers.

Covered activities: Participation in and attendance at the policy holder supervised and sponsored activities. This might include: meetings, fly fishing instruction, training, stream clean-up and maintenance. Travel arranged or provided by the policy holder is also included. Sponsored activities with duration of over seven days are not covered unless specifically agreed to by the insurer, but overnight camps with duration greater than seven days will be covered.

Trout Unlimited Chapter/ Council Accident Insurance Application

Chapter or council name (include chapter number) : ___________________________________________

POC Address: _____________________________________________________________________

City: _______________________                  State:  ___________                

Zip Code: ___________

Main point contact name:  __________________________  Volunteer title: ______________________

Contact’s e-mail address:  __________________________________________

Phone: ___________________________  Fax: __________________

Date of this application: ______________________

What are some examples of your main chapter activities during the year besides regular chapter meetings? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Can you give a rough estimate of the number of participants in those activities mentioned above based on past experience?  ______________________________________________________________________________

Are any of the activities of your chapter longer than seven days? If so, please describe:___________________________________________________________________________________________________________________________________________________

Do you have any participants in the above mentioned activities that are under the age of 18 years old?  If so how many and what activities? ____________________________________________________________________________________________________________________________________________________________

Signed:  ________________________________ Volunteer title: ____________ 

Date: _____________

Note:  An option for higher limits of $50,000 is available, same terms apply. This coverage cost is: $155       

Check here if you desire the higher limits ____

Please return your application and check to: Trout Unlimited, Inc., ATTN: Nick Halle, 1700 N Moore St. #100 Arlington, VA 22209.

On your check please note in the memo line “INSURANCE”