<p> Amateur Sports Insurance Application</p><p>SECTION I-GENERAL INFORMATION</p><p>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______</p><p>Type of Organization Team League Athletic Association Sale Association National Governing Body</p><p>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</p><p>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</p><p>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.</p><p>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.</p><p>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</p><p>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</p><p>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</p><p>Have you ever had an incident which resulting in an allegation of physical or sexual abuse? Yes No</p><p>If yes, please describe of the claim? ______</p><p>What was the outcome of the claim? ______If damages were paid, what was the total amount? $______</p><p>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.</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 shall also be subject to a civil penalty not to exceed five thousand dollars (5,000) and for each such violation.</p><p>Applicant’s Signature______Date______Amateur Sports Census of Participants</p><p>SPORTS AGE GROUP NUMBER OF NUMBER OF NUMBER OF SEASON START SEASON END PARTICPANTS TEAMS GAMES DATE DATE</p>