Sporting Event Liability Questionnaire

YOUTH CAMPS LIABILITY QUESTIONNAIRE LIABILITY COVERAGE TO INCLUDE PATICIPANT THIRD PARTY LIABILITY CLAIMS

CONTACT NAME: ______Contact person is: Owner Promoter Agent Other ______

PHONE #: ______FAX #: ______E-MAIL: ______

INSURED ENTITY NAME:______Insured is: Corporation Partnership Joint Venture Other

ADDRESS: ______

______

NAME OF EVENT:______

EVENT LOCATION: ______FACILITY NAME /ADDRESS ______CITY STATE ZIP DESCRIPTION OF EVENT:______

______

DESIRED EFFECTIVE DATE: ______

DESIRED EXPIRATION DATE:______

EVENT IS: DAY ONLY Yes No OVERNIGHT? Yes No

Number of STAFF/VOLUNTEERS PER DAY______

Number of PARTICIPANTS per day______

PARTICIPANT BREAKDOWN Number of: FEMALES MALES

AGE 12 AND UNDER

AGE 13-15 AGE 16-18

ADULTS Does your organization currently utilize a waiver of liability form? Yes No

Accident medical coverage is required in order to place participant liability coverage

Two typeS of coverage are generally available and your quote will include one of the following: Primary Accident - Covers as primary medical coverage. Excess Accident - Covers above and beyond what someone’s personal insurance will not cover. Both coverages usually have a deductible, and will be noted on your quotation.

INCLUDE PRICING FOR PARTICIPANTS ONLY / PARTICIPANTS AND STAFF (Please circle one)

NUMBER OF QUALIFIED MEDICAL PERSONNEL IN ATTENDANCE: ______

NUMBER OF EMT’S IN ATTENDANCE:______

DOES THE FACILITY HAVE AN EMERGENCY EVACUATION PLAN IN PLACE? ______

WILL YOUR ORGANIZATION BE SERVING OR SELLING ALCOHOL? ______

If yes, please describe: ______

HAS THIS EVENT BEEN HELD IN THE PAST BY THIS APPLICANT?______

IF SO, WERE THERE ANY LOSSES OR CLAIMS? ______

Please Describe ______

WAS THERE A PREVIUS INSURANCE CARRIER? ______If So, Who?______

ADDITIONAL INSURED (S) (USUALLY THE FACILITY HOSTING THE EVENT)

Facility name Street address

City State Zip ______

Contact Name Phone # Fax # E-mail address

Please Attach All Leases, Waivers, and Hold Harmless Agreements as well as a brochure or website address used to promote the event. (if available)

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties, as well as the withdrawal of such insurance and/or the denial of any coverages and/or claims.

Signed by applicant: ______Date ______

Printed name of applicant ______

EVENT INSURANCE NOW 800 NW 6TH AVENUE, SUITE 335 PORTLAND, OR 97209 PHONE: 503.227.0491 / FAX 503.227.0927 [email protected]

BROKER CONTACT (IF APPLICABLE)

AGENCY NAME______

REPRESENTATIVE______

PHONE # ______EMAIL ______Date ______