NAWGJ “Insurance Binder” Report

Date(s) of Clinic, Symposium or Meet __________________________________________________
Region_______________ State________________

This form is provided to NAWGJ members (not associate members) that wish to extend their insurance coverage to include the following gymnastics experiences.

Check which event.
_____Clinics (local, state, regional, national)
_____Critiques/consultation work
_____Workshops (especially when utilizing athlete demonstrators)
_____ Inter squad meets assigned or not assigned by NAWGJ
_____ Mock meets assigned or not assigned by NAWGJ
_____ Meets directly assigned by other organizations such as colleges, Y’s, etc.

I. Clinic, Workshop, Congress, Symposium....Paid for by Organizing group (i.e., state NAWGJ, National NAWGJ)

List clinicians:
Circle one: (The listed fee covers all NAWGJ clinicians at the event.)
Local $2 State $5 Regional $10 National $25
_______________________________________________________________________________

II. Meets (college, intersquad, mock) $3.00 fee....paid by each judge.

$3.00 is the fee for each judge to bind herself/himself to the NAWGJ insurance. Send forms and fee to those listed below. *
You, the member, will “attach” or “bind” yourself or your clinicians to your NAWGJ liability insurance when participating in these other situations by signing this form in triplicate. The clinicians must be members of NAWGJ to be eligible for coverage.

Name_________________________________ NAWGJ Ident. No. _________________________
Address_______________________________ Rating ___________Expiration Date____________
City __________________________________Site of Event _______________________________
State ______________________ Zip _______City_______________________________________
Phone No. ( )_______________________ State_____________________________ Zip ___________

I am a current member of NAWGJ.
This insurance binder form must be postmarked on or before the date of activity.

*All fees are non-refundable and nontransferable.
*Make checks payable to: NAWGJ
*Send fee and form to:
Betty Sroufe, Treasurer
2096 Rolling Hills Blvd.
Fairfield, OH 45014
*Send one copy to RID *Retain one copy for your records
Make copies of this original for your future use