<p> YOUTH CAMPS LIABILITY QUESTIONNAIRE LIABILITY COVERAGE TO INCLUDE PATICIPANT THIRD PARTY LIABILITY CLAIMS</p><p>CONTACT NAME: ______Contact person is: Owner Promoter Agent Other ______</p><p>PHONE #: ______FAX #: ______E-MAIL: ______</p><p>INSURED ENTITY NAME:______Insured is: Corporation Partnership Joint Venture Other</p><p>ADDRESS: ______</p><p>______</p><p>NAME OF EVENT:______</p><p>EVENT LOCATION: ______FACILITY NAME /ADDRESS ______CITY STATE ZIP DESCRIPTION OF EVENT:______</p><p>______</p><p>DESIRED EFFECTIVE DATE: ______</p><p>DESIRED EXPIRATION DATE:______</p><p>EVENT IS: DAY ONLY Yes No OVERNIGHT? Yes No</p><p>Number of STAFF/VOLUNTEERS PER DAY______</p><p>Number of PARTICIPANTS per day______</p><p>PARTICIPANT BREAKDOWN Number of: FEMALES MALES</p><p>AGE 12 AND UNDER</p><p>AGE 13-15 AGE 16-18</p><p>ADULTS Does your organization currently utilize a waiver of liability form? Yes No </p><p>Accident medical coverage is required in order to place participant liability coverage</p><p>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.</p><p>INCLUDE PRICING FOR PARTICIPANTS ONLY / PARTICIPANTS AND STAFF (Please circle one)</p><p>NUMBER OF QUALIFIED MEDICAL PERSONNEL IN ATTENDANCE: ______</p><p>NUMBER OF EMT’S IN ATTENDANCE:______</p><p>DOES THE FACILITY HAVE AN EMERGENCY EVACUATION PLAN IN PLACE? ______</p><p>WILL YOUR ORGANIZATION BE SERVING OR SELLING ALCOHOL? ______</p><p>If yes, please describe: ______</p><p>HAS THIS EVENT BEEN HELD IN THE PAST BY THIS APPLICANT?______</p><p>IF SO, WERE THERE ANY LOSSES OR CLAIMS? ______</p><p>Please Describe ______</p><p>WAS THERE A PREVIUS INSURANCE CARRIER? ______If So, Who?______</p><p>ADDITIONAL INSURED (S) (USUALLY THE FACILITY HOSTING THE EVENT)</p><p>Facility name Street address</p><p>City State Zip ______</p><p>Contact Name Phone # Fax # E-mail address </p><p>Please Attach All Leases, Waivers, and Hold Harmless Agreements as well as a brochure or website address used to promote the event. (if available)</p><p>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.</p><p>Signed by applicant: ______Date ______</p><p>Printed name of applicant ______</p><p>EVENT INSURANCE NOW 800 NW 6TH AVENUE, SUITE 335 PORTLAND, OR 97209 PHONE: 503.227.0491 / FAX 503.227.0927 [email protected] </p><p>BROKER CONTACT (IF APPLICABLE)</p><p>AGENCY NAME______</p><p>REPRESENTATIVE______</p><p>PHONE # ______EMAIL ______Date ______</p>