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Sports Application - Brokers

 
Please complete the online form below or download the PDF and fax it back to (973)-921-2876, ATTN: Sports or email to SportsInfo@BollingerInsurance.com

 

General Information
Name of Insured:
Insured Contact Name:
Title: Address:
City: State:
Zip:
Broker Name: Broker Title:
Broker Address: City:
State: Zip:
Telephone: Fax:
Email Address:  
 Please Confirm Email Address:
Insured is:
(select all that apply)
   (If other, fill in)
Years in Operation: Web Site Address:
Type of Organization:
Proposed Effective Date: Proposed Expiration Date:

Current Coverage Information

General Liability

Accident Medical
Insurance Company: Insurance Company:
  

Limits:

   

Limit:    

Occurrence: Deductible:
Aggregate: Aggregate:
Current Rate: Current Rate:
Annual Premium: Annual Premium:
Any losses in the last 3 years? Any losses in the last 3 years?

If you had any claims, you wil be asked to include complete loss history from your insurance company for all coverages.  We will contact you for this information.
Is Sexual Abuse Liability included? Do you want Sexual Abuse Liability quoted?
Current Limit:
Is Hired and Non-owned Auto coverage included? Do you want Hired/Non-Owned Auto quoted?
Annual Auto Rental costs, if any?
Is Host Liquor coverage included? Do you want Host Liquor quoted?

Additional Coverages Desired -

We will send you separate applications, or you may submit ACORD apps for each.
Please check all that apply:

General Program Information
Is insured a member of a national governing body? (i.e., Little League, Pop Warner, AAU):
If yes, what organization? If not, what rules and regulations are used (i.e., NCAA, high school, your own):

If insured has developed rules of play, they will be asked to submit it to us for review.
Are coaches certified?
 If yes, by whom?
 Are coaches paid?
Are officials/referees certified?
 If yes, by whom?
 Are officials/referees paid?
Is there a written safety program? Do you require persons certified in First Aid and CPR onsite or immediately available at all times? 
Do you utilize a waiver form? Waivers are required for all risks.  Please submit cop of waiver:
Do you have any traveling teams? If so, what is the maximum travel distance?
Any overnight travel? How many nights per year?:
Who arranges overnight travel?

Fundraising/Booster Clubs
Please describe any fundraising activities:
Annual Receipts from fundraising: $
Do you operate concession stands? Annual Receipts from concessions: $
Is there an organizational Booster club? If yes, are they a separate legal entity?
What are their specific activities:? If raising funds, do they conduct separate events other than those listed above?
If yes, please describe: Annual receipts:
$
Do you host any Special Events other than fundraisers?  If yes, please describe:

Fields/Facilities
How many field/facilities are utilized:
# Privately owned: # Owned by your organization:
 # Municipality owned:
Who is responsible for field/facility maintenance? Is the organization responsible for any field/facility 24 hours a day?

Sports Camps and Clinics

(please complete the appropriate section, if applicable.)
Name of Camp: Location of Camp:
Type of Camp: Age of Campers (ex: 7-12, 10-16, etc..):
Are Parental Waivers and Releases of Liability obtained from each participant?
 If not, are you willing to put in a requirement for obtaining signed waivers from each camper?
Do you have a written Crisis Management Plan?
 Written Emergency Medical Plan?
For overnight camps, describe your facilities for overnight accomodations for -

1) School
2) University/College
3) Other (please describe)
Do all facilities conform to life safety and security code standard for dormitories?

Day Camps and Clinics Exposure Basis
Session Dates
(example: 12/05/10-12/10/10)		 Name & Location of Camp/Clinic # of Days per Session x (# of Coaches + #Campers/Day) = Total Camper Days

Overnight Camps and Clinics Exposure Basis
Session Dates
(example: 12/05/10-12/10/10)		 Name & Location of Camp/Clinic # of Days per Session x (# of Coaches + #Campers/Day) = Total Camper Days

Certification
By signing this application, I hereby verify that the information provided is true and correct.
Applicant's Signature (type initials): Print Name & Title:
Agents Name (if any):
 Agent's License #:


Additional Insured Information
Are any additional insureds required? If yes, please list names, addresses and relationship to insured:
Are certificates of insurance required?
 If yes, please list names and addresses:

Sexual Abuse Information
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?
Do you routinely request and receive background investigations on the following individuals?
Employees:
Volunteers:
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, or what to do in the event you suspect abuse has occurred?
Do you have a written crisis management plan in place for dealing with members, employees, victims, parents, authorities and media if you have an incident of abuse?
Have you ever had an incident which resulted in an allegation of physical or sexual abuse?
If yes, please describe the allegation in full:
What was the outcome of the claim?
If damages were paid, what was the total amount? $

Certification:


By signing this application below, I hereby verify that the information provided is true and correct.

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 does not bind coverage until the completed 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 the claim for each such violation.

Applicant's Signature: (please insert your initials in lieu of signature)         Name of Broker:
Thank you!