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Sports Insurance Application - General

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

Current Coverage Information

General Liability

Accident Medical
Insurance Company: Insurance Company:
  

Limits:

   

Limits:    

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

If yes, you will need to include a complete loss history for all coverages.  We will contact you for this information.
Is Sexual Abuse and Molestation included?

Current Limits:
Do you want Abuse Liability Quoted?
Hired and Non-owned Auto coverage included? Annual Auto Rental costs, if any?

Additional Coverages Desired
Please check all that apply:

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

A copy of any of your own rules and regulations MUST accompany this application.
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 utilize a waiver form?
Waivers are required for all risks.  Please submit a copy.
Are there any traveling teams? If so, how far?
Any overnight travel? How often?
Who arranges overnight travel? Do you require persons certified in First Aid and CPR onsite or immediately available at all times?

Fundraising/Booster Clubs
Please describe any fundraising activities:
Annual Receipts from fundraising: $
Do you sell concessions? 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:
$
Any Special Events other than fundraisers?  If yes, please describe:

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

Participant Census
Sport Age Group # of Participants # of Teams # of Games Season Start Date Season End Date
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
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17)
18)
19)
20)

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

Sexual Abuse Information
Does your employment and/or 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 if 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 has been approved. In the event the Company does not approve your application, 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)

Thank you!