Supplemental Accident Insurance Application

The chapter/council premium for Fiscal Year 2023 will be $110 for $25,000 in coverage (Plan 1), or $150 for $50,000 in coverage (Plan 2). This policy term runs from April 1st 2022 through March 31st 2023.

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 it is received by Trout Unlimited. For your convenience, a copy of your policy will be uploaded into the Electronic Documents Storage in the Leaders Only Tools. If you are mailing a check instead of using the online payment form please write “INSURANCE” in the memo line of your check. Checks should be mailed to:

Trout Unlimited, Inc.,

ATTN: Nick Halle

1777 N. Kent St.

Suite 100

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: 52 weeks + 1
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:*

Please include chapter or council number above.

Main point contact name:*

Point of contact volunteer role:*

Point of Contact Address*

City State/Zip -

Point of contact e-mail address:*

Confirm Email -

Phone:*

Fax:

Please note if this is for Plan 1 ($25,000 in coverage) or Plan 2 ($50,000 in coverage).*

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?

Name*

Volunteer title:*

Date:*

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

This coverage cost is: $150 Check here if you desire the higher limits….

Pay via check

Check this box if you will be paying via check and not through the online payment form

Please return your application and check to: Trout Unlimited, Inc., ATTN: Nick Halle, 1777 N. Kent St. #100 Arlington, VA 22209.

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

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Supplemental Accident Insurance Application

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