Frazier Insurance Agency > Sports Event

General Information

Named Insured:
Applicant's Name:
Street Address:
City:
State:
Zip:
Phone:
Fax:
E-mail address:
Additional insured:

Name Address Interest
Additional insured:

Name Address Interest
Additional insured:

Name Address Interest

Liability Information

Desired effective date:
Desired termination date:
Please note that our standard limits of liability are $1,000,000 occurrence and $2,000,000 aggregate. Most venues/cities/locations require this minimal amount of coverage. We do not offer policies less than $1,000,000.
Spectator and Participant Liability $1,000,000 occ / $2,000,000 agg
We have the ability to raise our limits of liability over $1,000,000 occurrence—some venues/cities/locations require this. Selecting Excess General Liability is not advised unless a venue/city/location is requesting higher limits as this will increase the total premium. If you have questions about this, please contact our office.
Excess General Liability:
Require Non-Owned/Hired Automobile coverage? Yes No
Require Abuse/Molestation coverage? Yes No
Total Liability Requested:
$1,000,000 occ / $2,000,000 agg
Excess Accident Medical Requested: Per Claim
Has any insurance carrier cancelled or refused coverage? Yes No

Event Information

Please note that different types of sports or activities use different rates, so this information is vital for underwriting. Also, if your event is a camp or planned activity using multiple sports, please let us know all types which will occur.
Complete description of event/activity:
Number of estimated participants is very important for rating—we base a large portion of our premium on the number of participants. If you do not know exact numbers, using a range of participants will still be helpful for rating.
Estimated participants:

Age 12 & under Age 13-15

Age 16-18 Adults
Number of Events:
Seating capacity:
Emergency evacuation plan in place? Yes No
Qualified medical personnel in attendance? Yes No
Ambulance service in attendance? Yes No
What concessions will be sold?

Liquor Liability

Will alcoholic beverages be sold? Yes No
Is Applicant responsible for the sale of alcohol? Yes No
If Yes, provide estimated receipts:
Will there be BYOB (Bring Your Own Bottle)? Yes No
Will concessionaires provide you with certificates evidencing products liability with your organization named as Additional Insured? Yes No No Concessionaires

Affirmation and Signature

WARRANTY STATEMENT:

I hereby warrant and confirm that the above information, to the best of my knowledge, is true and correct, and further certify that I have read all of the questions and answers on this application. I understand this application is a requirement for coverage, a part of the contract and evidence of my acceptance of this insurance, and any falsification or misrepresentation will be deemed a breach of contract, voiding all insurance coverage. It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or the company until accepted by the company or companies in writing.

Title:
Name of Applicant:
Signature of Applicant:
Date:

Broker Information

Name of Authorized Agent or Broker:
Name of Agency
Agency Mailing Address:
E-mail:
Phone:
Fax:

(804) 754-7610 ~ 8002 Discovery Drive, Suite 415, Richmond, VA 23229 ~ ifrazier@frazierinsurance.com

Sports Event Application

Please note:

Age 12 & under	Age 13-15

Age 16-18	Adults