NAMED INSURED
*
APPLICANT'S NAME
*
STREET ADDRESS
*
CITY
*
STATE
*
ZIP
*
PHONE
*
FAX
EMAIL
*
DESIRED EFFECTIVE DATE
MM
DD
YYYY
DESIRED TERMINATION DATE
MM
DD
YYYY
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.
ESTIMATED PARTICIPANTS AND AGE
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.
NUMBER OF EVENTS
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
