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CLIMBING WALL QUESTIONNAIRE (Colonial General Insurance Agency, Inc)

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GLS-APP-47s (9-16) Page 1 of 4
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
CLIMBING WALL QUESTIONNAIRE
(Climbing, Tread and Bouldering)
Name of Applicant:
Website Address:
WALL INFORMATION
1. Type of Wall: Climbing Tread Bouldering
2. Height of wall: feet Width of wall: feet Year constructed:
3. Any portable walls utilized? ......................................................................................................................... Yes No
4. Any portable walls rented to others? .................................................................................................................................. Yes No
5. Was the wall constructed by a contractor who provided you with a certificate of insurance which includ-
ed completed operations coverage? ...........................................................................................................
Yes No
6. Was the wall constructed following Climbing Wall Industry Group (CWIG) or American Society of Test-
ing and Materials (ASTM) design standards? .............................................................................................
Yes No
7. Is there a minimum of six to twelve (12) inches of fall protection beneath the wall out to a distance of
six to eight feet? ...........................................................................................................................................
Yes No
8. What type of material is used in the landing area?
9. What is the maximum number of people on the wall at any one time?
10. Is there a line painted on the wall indicating the maximum height of the free climb zone? ........................ Yes No
If yes, height of line: feet
11. Are grasps permanently secured on the wall? ............................................................................................ Yes No
If no, are they only removed and relocated by employees? ........................................................................ Yes No
12. Number of auto-belay devices?
13. Number of top rope courses?
14. Is a daily inspection of the wall performed and results documented? ......................................................... Yes No
15. Is wall maintenance conducted by an independent contractor who provides you with a certificate of
insurance? ...................................................................................................................................................
Yes No
16. Any outdoor climbing? ................................................................................................................................. Yes No
If yes, provide details:
GLS-APP-47s (9-16) Page 2 of 4
EQUIPMENT INFORMATION
17. Does all the climbing safety equipment conform to the American Society of Testing and Materials
(ASTM) and/or the International Association of Alpine Associations (UIAA) standards? ...........................
Yes No
18. Is all climbing safety equipment inspected daily with inspection results documented? .............................. Yes No
19. Do you rent any equipment? ....................................................................................................................... Yes No
If yes, provide details:
20. Do you sell any equipment? ........................................................................................................................ Yes No
If yes, provide details:
SAFETY AND TRAINING RULES
21. Are safety rules posted? .............................................................................................................................. Yes No
22. Are climbers required to watch a training video prior to first climb? ............................................................ Yes No
23. Are climbing classes offered? ...................................................................................................................... Yes No
24. Is there a method to identify approved users prior to their use of the wall? ................................................ Yes No
25. Is there a documented training program for all wall users, which includes:
Yes No Yes No
Harness and rope inspection procedure? Rules for climbing, tread, bouldering wall(s)?
Proper belaying techniques? Setup and takedown procedures?
Emergency takedowns? Procedures for reporting problems?
Belay device failure or entrapment?
STAFF INFORMATION
26. Is a full-time, first-aid or CPR certified staff member always present? ........................................................ Yes No
27. Is this full-time staff member certified to belay on the wall and understand the safety rules? .................... Yes No
28. Is a full-time staff member positioned to have a clear view of the wall and participants? ........................... Yes No
MEMBERS
29. Do membership agreements contain a hold harmless clause (Liability Waiver) and require signature
indicating acceptance? ................................................................................................................................
Yes No
30. Are minors permitted to use the facility? ..................................................................................................... Yes No
31. Minimum age of participants? ...................................................................................................................... Yes No
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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
GLS-APP-47s (9-16) Page 3 of 4
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be
presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or
any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or
statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or con-
ceals, 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties
under state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
GLS-APP-47s (9-16) Page 4 of 4
NEW YORK 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 and the stated value of the claim
for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
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CLIMBING WALL QUESTIONNAIRE (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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