Gimli Motorsport Park – 2016 Track Rental Event Order Form

Gimli Motorsport Park - Informational Bulletin - 2016 | 1
OVERVIEW
COMMERCIAL GENERAL LIABILITY/PARTICIPANT ACCIDENT
BASIC INFORMATION
Named Insured:
GIMLI MOTORSPORT PARK (TRACK RENTALS ONLY)
Policy No.:
E2MS000070
LIABILITY LIMITS AND DEDUCTIBLES
Liability Limits:
$
5,000,000 Each Occurrence, Bodily Injury and Property Damage Liability
$
5,000,000 Personal Injury and Advertising Injury Liability
Participant
$
10,000 Accidental Death and Dismemberment (Non Motorcycle)
Accident:
$
25,000 Accidental Death and Dismemberment (Motorcycle)
Deductibles:
$
1,000 each occurrence Bodily Injury/Property Damage
$
1,000 property damage-SEF 94 deductible
COVERAGE DETAILS




Injury to Participants
Any person or organization engaged in operating, managing, sanctioning, or sponsoring the covered program
or providing the premise for a covered program including officials of the covered program are included as
additional insured
Any participant, competition vehicle owner and competition vehicle sponsor are included as additional
insured
Volunteers are included as additional insured
Exclusions:

Events or activities not scheduled or not usual to your business

Fireworks and concerts

Amusement devices (mechanically operated)

Intended or expected injury to others

Any obligation of the insured for a workers’ compensation, disability benefits or unemployment
compensation law or similar law

Bodily injury to an employee of the insured arising out of and in the course of employment of the insured

Employment related practices, sexual harassment and discrimination

Bodily injury to any person in a restricted area from whom you have not obtained a valid waiver and release
and waiver unless by inadvertent error

Bodily injury or property damage arising out of the ownership, use or operation by or on behalf of the
insured of any automobile other than competition vehicles or official vehicles during a covered program
while on the premises

Watercraft, Aircraft, Air cushion vehicles

Property damage to property you own, property you sell or give away, property in your care, custody and
control

Property damage to property owned, leased to, rented to or used by any participant or employee when in
the restricted area

Limited pollution

Nuclear liability, war and terrorism, asbestos
The coverage above as presented is only a summary and is subject to the detailed terms, provisions and conditions of the policy to
which it pertains.
Gimli Motorsport Park - Informational Bulletin - 2016 | 2
EVENT INSURANCE ORDER FORM
IF A CERTIFICATE OF INSURANCE IS NEEDED, PLEASE SUBMIT THIS APPLICATION, ALONG WITH PREMIUM
TWO (2) WEEKS PRIOR TO THE EVENT TO ENSURE PROPER MAIL TIME.
1.
Club, Association or Promoter:
Address:
Phone:
Fax:
2.
Type of Event:
3.
Track:
4.
Event Dates:
5.
Premium Remitted:
7.
Additional Insureds and Relationship:
8.
Authorized Signature:
E-Mail:
Check No.:
PREMIUM SUMMARY
MOTORCYCLE LAPPING: $5,000,000 Liability/$25,000 Accidental Death and Dismemberment
Large Track
Per day: $12ϳϱ.00 plus $10Ϯ.00 PST plus $1ϬϬ.00 Risk Management Fee (RMF) plus $1ϯ͘ϬϬ HST
Development Track
Per Day: $9ϳϱ.00 plus $7ϴ.00 PST plus $100.00 RMF plus $13.00 HST
AUTOMOBILE LAPPING: $5,000,000 Liability/$10,000 Accidental Death and Dismemberment
Large Track
Per Day: $8ϳ5.00 plus $6ϴ.00 PST plus $100.00 RMF plus $13.00 HST
Development Track
Per Day: $6ϳϱ.00 plus $5ϰ.00 PST plus $ϭϬϬ.00 RMF plus $ϭϯ͘ϬϬ HST
Total
$
1,49Ϭ͘ϬϬ
Total
$
1,1ϲϲ.00
Total
$
10ϯϭ.00
Total
$
842.00
PAYMENT IN FULL ALONG WITH EVENT INSURANCE ORDER FORM REQUIRED PRIOR TO EVENT
**In the event of a claim arising out of your event, you will be responsible for payment of the deductible**
Gimli Motorsport Park - Informational Bulletin - 2016 | 3
TRACK LAPPING REGULATIONS
WAIVER AND RELEASE FORMS
•
All participants-drivers, crew, officials, workers and anyone allowed access to the restricted area must
read, complete and sign the appropriate waiver and release.
•
•
•
Waivers must show name and date of the event at the top and all signatures must be witnessed.
Do not fold or bend waivers at any time including during storage.
Keep waivers in a secure place for at least 5 years. Store flat and dry. Minor waiver and release forms
should be stored longer.
GUIDELINES
•
•
There must be a designated person who is responsible for overall control of the day.
•
•
•
Passing must only take place in designated zones and must be clearly marked.
•
•
•
Drivers being passed must acknowledge they are allowing a pass-by use of a raised arm or turn signal.
All drivers should be given instruction on track layout, entry and exit, emergency procedures, passing
regulations and other information pertinent to the event.
Aggressive driving is not permitted.
Organizer must separate on track sessions taking into consideration speed, type of vehicle and
experience of the drivers.
Cars being passed are to remain on the racing line.
Drivers should signal their intention to enter the pits.
Safety
•
•
No person or property must be in harm’s way on the track of paddock.
•
Track Organizer must have an emergency plan. Please refer to StoneRidge Specialty Risk Management
Manual for guidance. Visit www.StoneRidgeSpecialty.ca.
On track marshal must be placed before blind corners and where track is not visible to the Head marshal
radios must be utilized.
Drivers
•
•
•
Drivers must be of age to obtain a drivers license.
•
Novice drivers should not be permitted on track as same time as experienced drivers until orientation is
completed.
•
Passengers are allowed but must sign the appropriate waiver and release and have the same personal
protective equipment as the driver.
•
•
•
All drivers and passengers must wear helmets.
Driver is responsible for conduct of their crew and guests.
Consumption of alcohol or use of any illegal drug by any participant before and during the event is
forbidden.
All drivers and passengers must wear seat belts.
Recommended that windows be maintained in up position during on track session.
Gimli Motorsport Park (track rental)
Insurance Policy
TERMS AND CONDITIONS
1. ___I understand and agree that the Motorsport event insurance I have applied for is provided thru StoneRidge
Specialty.
2. ___I understand and agree that I will be provided liability and participant accident insurance as per the application
and information provided to StoneRidge Specialty.
3. ___I understand and agree that the coverage provided is only for the event(s) and/or activities that were submitted
and approved by StoneRidge Specialty.
4. ___I understand and agree to stage the event as per the information provided prior to acceptance and that any
change to the schedule and/or operations must be approved by StoneRidge Specialty.
5. ___I understand and agree that all PARTICIPANTS must read, complete and sign the appropriate waiver and release.
6. ___I understand and agree that I have been provided with the minor waiver, parental consent waiver and adult
waiver along with instructions on proper use. I will copy the waiver as required to make sure all participants have a
waiver available to read, complete and sign.
7. ___I understand and agree that within 5 days of the completion of the event, I will mail, fax or email a copy of the
completed waivers to StoneRidge Specialty.
8. ___I understand and agree that all incidents/accidents will be recorded and reported to Canadian Tire Motorsport
Park. Incident forms and claims handling information has been provided to me.
9. ___I understand and agree that any statement of claim or lawyer letter or any other reference to a claim will be
forwarded immediately to StoneRidge Specialty.
10. ___I understand and agree that in the event of a claim arising from the event, I will be responsible to pay the $1,000
deductible.
11. ___I understand that the application and all information supplied is part of the application process and will be relied
upon by the insurance company in determining whether to provide the insurance coverage herein requested. Any
material misrepresentation or false statement may entitle the insurance company to rescind the policy, voiding all
insurance coverage. I hereby warrant, represent and confirm that I have read all of the questions and answers on the
application and that, to the best of my knowledge, all information provided in this application is complete, true and
correct.
12. ___it is understood and agreed that no insurance is in effect until the application is accepted by the company or
companies.
Name:_______________________________________________________________
Email:________________________________________________________________
Phone Number: ________________________________________________________
Date:_________________________________________________________________
195 Franklin Boulevard, Unit 6 – Cambridge, Ontario - N1R 8H3
Phone: (226) 318-1744 Fax: (905) 648-7399 – www.StoneRidgeSpecialty.ca
Gimli Motorsport Park - Informational Bulletin - 2016 | ͷ
Payment Option Form
Client Information
Named Insured:
Customer/Account Code:
Policy No:
Payment Options/Methods Available: Please Check One
1. Payment in full by cheque required prior to event.
2. Credit Card payment – Visa/MasterCard only (2.9% processing fee applies).
I hereby authorize StoneRidge Specialty Insurance, for the purpose of paying the insurance premium
and terms of my insurance policy (s), to charge my Visa/MasterCard the amount of
.
I am aware a 2.9% processing fee applies.
Card Number:
3 Digit Security Code:
Expiry Date:
Card Holder Name:
Signature
Date
3. Direct Deposit Banking.
Banking information is as follows:
BMO Bank of Montreal
Transit #: 3319
Account # 1998-029
Payment can be made at any BMO Branch and deposited into our account. Please ask the teller to make
note on the deposit with your name /client code (GIM001).