SECTION I-GENERAL INFORMATION Name of Insured______
Total Page：16
File Type：pdf, Size：1020Kb
Amateur Sports Insurance Application
SECTION I-GENERAL INFORMATION
Name of Insured______Contact Name______Address______City______State______Zip______Mailing Address______City______State______Zip______Telephone ( )______Fax ( )______E-mail Address______Applicant is Individual Corporation Partnership Other______
Type of Organization Team League Athletic Association Sale Association National Governing Body
Proposed Effective Date: ______Proposed Expiration Date: ______Desired Limit of Liability: Limits: Occurrence______Each Occurrence______Products/Completed Operation: ______Personal Injury and Advertising Injury: ______Fire Legal: ______Medial Payments: ______Will the insured require athletic participants coverage? Yes No If so, please provide answer to the following questions: Will participants be covered by medical insurance? Yes No Limits______Who is responsible for maintaining the fields?______Are the fields/facilities inspected prior to play? ______Does the facility contain bleachers? ______Does the league have written regulations with regard to roster size? ______Does the league sponsor camps? Yes No Are any camps overnights? Yes No Are any coaches paid or volunteer? ______Does the league have written policy with regard to the hiring of coaches? Yes No
Please attached the following information to this application: Currently-valued, hard-copy loss runs for the previous five years. Copies of written regulations to which the Association adheres. Brochures and Promotional Material about the Association. Copy of expiring policy. SECTION II-CURRENT COVERAGE INFORMATION
General Liability Accident Medical Carrier______Carrier______Limits: Occurrence______Limits: Occurrence______Aggregate______Aggregate______Current Rate______Current Rate______Annual Premium______Annual Premium______Have there been any losses in the last 5 years Yes No Have there been any losses in the last 5 years Yes No If yes, please include complete loss history for all coverage.
Is sexual Abuse and Molestation Included? Yes No Limits: Occurrence______Aggregate______If no, is coverage desired? Yes No Hired and Non-owned Auto coverage included? Yes No If no, is coverage desired? Yes No Annual rental costs, if any: $______Would you be interested in the following coverages: Property Yes No Crime Yes No Equipment Yes No D&O Yes No SECTION III-GENERAL PROGRAM INFORMATION Are you a member of a national governing body? (i.e. Little League, Pop Warner. AAU) Yes No If yes, what organization: ______If not, what rules and relations are used? (i.e. NCAA, high school, your own)______Please include a copy of any of your own rules and regulations.
Are coaches certified or do you provide special training? Yes No Explain______Are Officials/referees paid? Yes No Is there a written safety program? Yes No Do you utilize a waiver form? Yes No If yes, please attached a copy of the waiver form. Are there any traveling teams? Yes No If so, how far? ______Do you require that persons certified in first aid and CRP are present on site or immediately available at all times? Yes No Please detail any fundraising activities______Please complete the attached census indicating number of participants by sport and age group. SECTION IV-OTHER INFORMATION Are any additional Insureds required? Yes No If yes, please list names, addresses and relationships Provide attachment if necessary. ______Are certificates of insurance required? Yes No If yes, please list names, and addresses. ______SECTION V-SEXUAL ABUSE Does your employment and volunteer application include questions about whether the individual has ever been convicted of any crime, including sex-related or child-abuse related offenses? Yes No
Do you routinely request and receive background investigations on the following individuals? Employees Yes No Volunteers Yes No Do you discuss (at staff/volunteer orientations) child/sexual abuse, including how to recognize the signs, what to do if a member reports someone molested him/her, etc. at staff orientation? Yes No
Do you have a written crises management plan in place for dealing with members, employees, victims, parents, authorities and media if you have an incident of abuse? Yes No
Have you ever had an incident which resulting in an allegation of physical or sexual abuse? Yes No
If yes, please describe of the claim? ______
What was the outcome of the claim? ______If damages were paid, what was the total amount? $______
Coverage shall not be bound until the company approves the applicant’s completed application and premium payment is received. The Company’s receipt of premium dies not bind coverage until the complete application is also approved. In the event the company does not approve your applications, your premium payment will be refunded.
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 shall also be subject to a civil penalty not to exceed five thousand dollars (5,000) and for each such violation.
Applicant’s Signature______Date______Amateur Sports Census of Participants
SPORTS AGE GROUP NUMBER OF NUMBER OF NUMBER OF SEASON START SEASON END PARTICPANTS TEAMS GAMES DATE DATE