Club InsurPak

Checklist of Required Items

• Completed Club InsurPak Application
• Past Four Years of Hard-Copy Loss Information for each coverage being
  submitted
• Copies of Club Brochure, Membership Application, Nursery Schedule,
  Event’s Schedule and any other Membership Agreement Forms
• Automobile Coverage
  • Completed Automobile ACORD Applications
  • Copies of Licenses
  • Schedule of Current Vehicles
• Completed and Signed Club InsurPak Application
• Statement of Values
• Fraud Warning Notice
• Excess Crime Coverage
• Liberty Mutual’s National Workers’ Compensation Dividend Safety Group Program
  • Complete Workers’ Compensation Application
  • Notice of Assignment Form must be signed by Club Owner
  • Liberty Mutual’s Workers’ Compensation Application
  • Assignment Form
• Brokerage Agreement including W9 form

Claim Reporting Services

Report all claims directly to Liberty Mutual:

• Liberty Mutual
  800-266-2800
  (24 Hours Per Day)
• Liberty Mutual Insurance
  800-344-0207
  (24 Hours Per Day)

For Any Questions or Clarifications Contact:

• Creative Agency Group
  Contact: Allison Schlumpf
  800-888-8381, Ext. 185
  (8:00 AM to 5:00 PM Eastern Standard Time)
  • Club Incident Report Complete For All Claims
• Letter of Authority
  • Please Include an Original Letterhead and Sign the Enclosed Letters to be Utilized as Needed
    • Liberty Mutual
• Liberty Mutual's Coverage Extensions
  • Property Extension Endorsement
  • Time Element Extension
  • General Amendatory Endorsement