CONTACT NAME
*
CONTACT PHONE
*
Country
(###)
###
####
CONTACT EMAIL
NAME INSURED
*
STREET ADDRESS
*
CITY
*
STATE
*
ZIP
*
FORM OF BUSINESS
*
INDIVIDUAL
CORPORATION
JOINT VENTURE
LIMITED LIABILITY COMPANY
LIMITED LIABILITY PARTNERSHIP
PARTNERSHIP
OTHER
TYPE OF BUSINESS IF OTHER
NUMBER OF EMPLOYEES/VOLUNTEERS
*
EVENT LOCATION(S)/ADDRESS(ES)
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
REQUESTED COVERAGE DATE START
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MM
DD
YYYY
REQUESTED COVERAGE TERMINATION DATE
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MM
DD
YYYY
EVENT TYPE
*
NAME OF EVENT
*
DESCRIPTION OF SPORTS/ACTIVITY
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LEVEL (PLEASE CHECK ONE)
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Checkbox
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.
REQUIRE NON-OWNED / HIRED AUTO COVERAGE?
REQUIRE ABUSE / MOLESTATION COVERAGE?
WILL THERE BE ONE-ON-ONE TRAINING?
EXCESS ACCIDENT MEDICAL REQUESTED?
$10,000
$25,000
$50,000
$100,000
HAS ANY INSURANCE CARRIER CANCELLED OR REFUSED COVERAGE?
COMPLETE DESCRIPTION OF EVENT/ACTIVITY
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.
NUMBER OF PLAYING DAYS
Will participants be taking more than one lesson?
Will participants stay overnight?
Does the organization hold any Non-Athletic Participant fundraising activities?
What type of security will you be using?
Desired Accident Medical Deductible:
Will you be using any pyrotechnics, or use of mechanical devises that will be ridden (excluding sporting equipment)?
Does any volunteer, owner, coach, or official have a criminal record, or has ever had a criminal record?
Have you had any claims in the past five (5) years?
Maximum number of spectators at any individual event or location:
EMERGENCY EVACUATION PLAN IN PLACE?
QUALIFIED MEDICAL PERSONNEL IN ATTENDANCE
AMBULANCE SERVICE IN ATTENDANCE?
WHAT CONCESSIONS WILL BE SOLD?
WILL ALCOHOLIC BEVERAGES BE SOLD?
IS APPLICANT RESPONSIBLE FOR THE SALE OF THE ALCOHOL?
IF YES, PROVIDE ESTIMATED RECEIPTS
WILL THERE BE BYOB (BRING YOUR OWN BOTTLE)?
WILL CONCESSIONS PROVIDE YOU WITH CERTIFICATES EVIDENCING PRODUCTS LIABILITY WITH YOUR ORGANIZATION NAMED AS ADDITIONAL INSURED?
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.
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TITLE
NAME OF APPLICANT
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SIGNATURE OF APPLICANT
*
DATE
*
NAME OF AUTHORIZED AGENT OR BROKER
NAME OF AGENCY
AGENCY MAILING ADDRESS
EMAIL
PHONE
FAX
Name
First Name
Last Name
Estimated Gross Receipts: $
Have you ever filed for bankruptcy?
Have you ever had insurance cancelled, or non-renewed for any reason?
Does the applicant use a waiver and release?
NAME INSURED
STREET ADDRESS
CITY
STATE
ZIP
CONTACT NAME
PHONE
EMAIL
TYPE OF BUSINESS
ABUSE/MOLESTATION COVERAGE (OPTIONAL)
Additional Premium Fully Earned at Policy Inception
EXCESS LIABILITY COVERAGE COVERAGE (OPTIONAL) PLEASE CHECK BOX TO THE LEFT
Follow-form Excess Liability Coverage with the following Per Occurrence / Aggregate limit can be added for an additional premium as indicated below:
HIRED/NON OWNED AUTO LIABILITY COVERAGE (OPTIONAL)
$1,000,000 Hired/Non Owned Auto Liability Coverage can be added for an additional
premium/taxes/fess
What is the estimated cost of hire?
Federal Employer Identification Number (FEIN):
Describe fully all operations conducted by you which involve the use of automobile (passenger carrying or otherwise):
Is a safety belt use policy in place for all passengers?
Describe fully all operations conducted by you which involve the use of automobile (passenger carrying or otherwise):
What is the average number of days per week that each vehicle is operated?
What is the average number of hours per day that each driver drives one or more of the vehicles?
What percentage of driving is night driving?
What evidence of auto insurance does your organization required from employees/volunteers using their personal autos?
Is a bus being chartered?
Are any children being transported in vans or buses?
Are the drivers employees?
Are the drivers volunteers?
Are the drivers parents?
Are the drivers coaches?
Does the applicant have a formal written policy that addresses acceptable business use of personal vehicles?
Does the applicant check MVR’s (motor vehicle records) and apply disciplinary procedures for unacceptable MVR’s?
Is there a verification procedure for personal auto coverage and personal use reimbursement?
Does the applicant have a driver safety program?
Do employees and/or officers and partners lease or rent autos on the applicant’s behalf?
Do you provide virtual online training/coaching/instruction?
Are you selling alcohol?
Will you be using a third party catering service?
To the best of my knowledge and belief all statements made in the Application for Insurance are true. Agreeing electronically to this document does not bind the Applicant to purchase the insurance, but it is agreed that this Application shall be the basis of the contract, should a policy be issued.
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I AGREE
DO NOT AGREE
