Additional Facility Insurance

If you require additional Insurance Certificates for multiple practice facilities, please fill out the form below.

Insurance Details

GL/XS/PA – EO + SAM
General Liability / Excess Liability / Participant Accident – Evidence of Coverage with Sexual Abuse and Molestation coverage shown.
This is your standard evidence of coverage issued to a club or any third party.  

GL/XS/PA – AI + SAM
General Liability / Excess Liability / Participant Accident – Additional Insured with Sexual Abuse and Molestation coverage shown.
This certificate template is proof of insurance for the region and/or a club AND also provides additional insured status for third party entities, such as venue owners.

INCIDENT REPORT FORM

Should an injury occur at a sanctioned USAV/Great Plains Region event. This could include tournaments, practices, or clinics but must be sanctioned.

An Incident Report form should be completed ON SITE at the time of injury. It should be signed by the Regional Contact, Event operator, Coach, or USAV staff member and Medical Personnel who were present at the time (if applicable).  

Send Incident Report form to Region Office
(email: membership@gpvb.org or Fax: 402-593-9760)

MEDICAL CLAIM FORM

In the case that a Medical Claim needs to be filed, the injured party/parent will need to complete the Medical Claim form and email it to: claims@agadm.com

  • Should be completed whenever claim results from an injury incurred at USAV sanctioned events.
  • Should be completed after you receive the medical bills.  

SAFESPORT - REPORTING ABUSE

CRITICAL INFORMATION FOR ALL GREAT PLAINS MEMBERS
The Great Plains Region and USA Volleyball is committed to the safety of all participants. Both entities have ZERO TOLERANCE for abuse and misconduct.

This includes not only on-court safety, but also off-court safety in any part of USA Volleyball’s programs. USA Volleyball is committed to creating safe and fun environments for youth. This includes, but not limited to, providing training, educational materials, and resources for our regions, clubs, coaches, parents, and athletes.