Supplemental Accident Insurance Application

YOU MUST SUBMIT THE BELOW APPLICATION TO OBTAIN AN SAI POLICY
REGARDLESS OF HOW YOU WILL BE PAYING FOR THE POLICY.

Supplemental Accident Insurance Application

The chapter/council premium for Fiscal Year 2025 will be $155 for $100,000 in coverage.This policy term runs from April 1st 2024 through March 31st 2025. There are no longer multiple levels of coverage.

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

Payment for SAI policies can be made via credit card, check, or ACH transfer. You still must complete and submit the below application in order to obtain a policy.
- To purchase a SAI Policy online, click here.
If you prefer to mail a check rather than use the online payment options, please write “SUPPINSUR” in the memo line of your check. Checks should be mailed to:

Trout Unlimited, Inc.,

ATTN: Nick Halle

1700 N. Moore St.

Suite 2005

Arlington, VA 22209

Policy cover is:
- Medical expenses arising out of an accident: $100,000 per participant per accident
- Dental expenses arising out of an accident: included in above limit
- Deductible per: None
- Benefit period: 52 weeks
- Plan coverage: Full excess
- Accidental death benefit: $25,000
- Accidental dismemberment benefit: Up to $50,000 per Schedule of Covered Losses
- 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:
Date of this application:*
MM slash DD slash YYYY
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:*
MM slash DD slash YYYY
Pay via check
- Check this box if you will be paying via check.
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

Supplemental Accident Insurance Application

Trout Unlimited Chapter / Council Accident Insurance Application