USPC Optional Accident Insurance Application

Use when non-Pony Club Members will be participating in a USPC activity (shows, clinics, etc.)

Region*
Pony Club*
DC*
Phone*
Pony Club Address*
City*
State*
Zip*
Email*
Application is hereby made for insurance to be provided in accordance with the terms and conditions of the Master Policy issued by AIG (American International Group, Inc.), and on file with the United States Pony Clubs, Inc. as follows:

USPC Optional Accident Insurance Application

Covering each non-Pony Club participant while he or she is taking part in a Pony Club Horse Show or other specified Special Event sponsored and supervised by the Pony Club.

EXCLUSIONS: Roughstock

Medical Expense Limit: $25,000 each accident
Accidental Death & Dismemberment: $5,000
Events
Event Name*

Start Date*
MM slash DD slash YYYY

End Date*
MM slash DD slash YYYY

Rate / Day
$28

Premium
$0.00
Rate/Day
Total: $0.00
Specialty Program Insurors (SPI)
A Division of Haas & Wilkerson Insurance
4300 Shawnee Mission Parkway
Fairway, KS 66205
913-432-4400

ACKNOWLEDGEMENT

We acknowledge receipt of the above Application and we have arranged for the insurance requested under the Master Policy issued for the United States Pony Clubs, Inc. The terms and conditions of the Policy shall control all coverage provided.
Name
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