<p>ADVENTUREGUARD SUPPLEMENTAL QUESTIONNAIRE – CLIMBING WALLS Page 1 of 2</p><p>THIS IS A SUPPLEMENTAL QUESTIONNAIRE ONLY. PLEASE COMPLETE THE ADVENTURE ACTIVITIES APPLICATION FIRST. APPLICANT: Legal Name of Company: Operating Name: </p><p>ROCK CLIMBING OPERATIONS: 1) Is your climbing wall: Indoor/ Fixed Portable Both 2) Who built your wall? 3) In what year was it built? 4) Do you offer any outdoor climbing (mountaineering, rappelling, rock climbing)? Yes No a. If YES, please complete the Outdoor Climbing supplement. 5) Are your guides certified by the Association of Canadian Mountain Guides? Yes No a. If NO, please state your guides’ certification(s): 6) What type of belay device is used? 7) Do you use an Auto Belay device? Yes No a. If YES, please state manufacturer: b. How old is the device? 8) Do you ensure that ALL equipment is inspected and tested according to manufacturer’s specifications? Yes No a. If NO, please explain why: 9) Do you allow climbers to use personal equipment? Yes No a. If YES, describe your policy with respect to screening of personal equipment used by others: 10) Do you offer a belay course? Yes No a. If YES, please provide brief outline of your course, including who teaches it, duration, and standards for passing the course: </p><p> b. What is the minimum age to take the belay course? 11) Do you have a bouldering section? Yes No a. If YES, what is the average height? b. Describe supplemental padding of area: c. Are warning signs posted and clearly worded? Yes No 12) Please indicate number of: a. Annual Members: b. Drop in Members: 13) Please indicate: a. Total gross receipts: b. Indoor Wall receipts: c. Portable Wall receipts: d. Please indicate if you offer any of the following, and advise gross receipts for each: i. Birthday Parties Yes No $ ii. Pro Shop Yes No $ iii. Concession Yes No $ WESTERN CANADA T 604.689.1501 F 604.689.5663 Rev. Nov 7, 2014 www.premiergroup.ca ONTARIO & ATLANTIC CANADA T 519.850.1610 F 519.850.1614 ADVENTUREGUARD SUPPLEMENTAL QUESTIONNAIRE – CLIMBING WALLS Page 2 of 2</p><p> iv. Day Camps with outings Yes No $ </p><p>THIS IS A SUPPLEMENTARY QUESTIONNAIRE ONLY. A QUOTATION CANNOT BE OFFERED WITHOUT THE COMPLETED ADVENTURE ACTIVITIES APPLICATION.</p><p>Premier Canada Assurance Managers Ltd. (WEST) Inc. is one of Canada’s largest Managing Underwriting Agents. The underwriting insurance carrier varies by line of business and region - please refer to specific quote for declaration of the underwriting insurance company(s).</p><p>WESTERN CANADA T 604.689.1501 F 604.689.5663 Rev. Nov 7, 2014 www.premiergroup.ca ONTARIO & ATLANTIC CANADA T 519.850.1610 F 519.850.1614</p>