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SPECIAL EVENT Application for Insurance PRG 142143 (01-22) ©All rights reserved. Page 1 of 5 1. COMPLETE REPONSES ARE REQUIRED ON ALL QUESTIONS 2. APPLICATION MUST BE SIGNED 3. EVENT DATES

March 14, 2021 COMMUNICABLE DISEASE EXPOSURE AND INFECTION ASSUMPTION OF RISK, HOLD HARMLESS, RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT ________________________________ FILL IN

CONSENT FOR ELECTRONIC DISCLOSURE, GENERAL FRAUD STATEMENT & COMPENSATION PLEASE READ, COMPLETE AND SIGN/DATE, WHERE INDICATED CONSENT FOR ELECTRONIC DISCLOSURES UNDER THE ELECTRONIC

NAME OF TRACK FACILITY: Date: Date-0: Printed Name of Minor: DOB: Textfield-1: Printed Name of Parent or Guardian 1: Printed Name of Parent or Guardian 2: All Event Dates: Yes:

Name of Track andor Event: Event Dates: 1: Mother: Guardian: Guardian-0: Textfield: Father: Mother-0: Guardian-1: Guardian-2: Printed Name of MINOR Participant: DOB:

MINOR RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT (READ CAREFULLY BEFORE SIGNING) ALL TRACKS/ALL EVENTS ALL DATES ____________________________________________

Acuerdo de liberación y exención de responsabilidad, asunción de riesgos e indemnidad Nombre de la pista o del evento: _____________________ Fecha(s) del evento: ___________________

Nom de la piste etou de Ievenement: Dates de Ievenement: Textfield-0: Textfield-1: Textfield-2: Textfield-3: Textfield-4: Textfield-5: Textfield-6: Textfield-7: Textfield-8:

Release and Waiver of Liability Assumption of Risk and Indemnity Agreement Event Name/Location: Event Date(s): IN CONSIDERATION of being permitted to compete, officiate, observe,

Abuse & Molestation Supplemental Questionnaire Named Insured I DBA Facility Address City I State I ZIP Code 1. Type of Facility 2. Please check each that describes your current and/ or planned

Batting Cages Supplemental Questionnaire Separate application required for each location I. General InformationNamed Insured I OBA Facility Address Website I Email II. Batting Cage

Health Club Facility Swimming Pool Supplemental Application I. General Information Named Insured I DBA Facility Address Website I Email How many pools? Indoor Outdoor II. Pool

Hired & Non-Owned Auto Supplemental Application Separate application required for each location To be completed and returned with Commercial Auto ACORD application I. General Information Named

Liquor Liability Application This is a warrantee application for primary or excess liquor liability insurance. All questions must be answered. If the answer to any question is none, state 'none'

Skating Facility Supplemental General Liability Application Separate application required for each location I. General Information Named Insured I DBA Facility Address Website I Email D

NAME OF TRACK FACILITY: I HAVE READ THIS RELEASE: SIGNATURE: PRINT NAME: TITLE: DATE SIGNED: CREDENTIALS: ADDRESS:

PAGE 1 OF 2©2026 Innovation Growth Partners Specialty, LLC. All rights reserved. | igpspecialty.com | Rev. 02.17.26 Natural Disaster Program Application PERILS TO BE COVERED • Flood-only

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