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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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  • 64 check-boxes
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C‐APP038‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - SPORTS CAMPS, CLINICS AND LEAGUES - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
OPERATIONS / EXPOSURES
Sports Camp Type (see next page for Sports Clinics and Sports Leagues activities):
Day Camp Other (describe): __________________________________________________________
Agency Non-Profit Private Religious Other (describe): _____________________
Participant Ages:
Under 5 5 to 12 13-16 16 – 21 22 to 59 60 and over
Participant Genders:
Boys Girls Coed
C‐APP038‐0815 Page2of4
SPORTS CAMPS, CLINICS AND LEAGUES - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES (continued)
Participants – Developmental Disabled:
Developmental disability exposures. If yes, percentage of total annual participants: _______ %
Types of activities provided for developmentally disabled:
Coaches:
Coaches If yes, number of coaches: ______
Accredited If yes, by whom: _____________________________________________________________
Carry their own liability insurance and certificates provided to applicant
Activities – Sports Clinics and Sports Leagues (only the types listed below are acceptable):
Archery Baseball Basketball Bowling Running Softball Tennis
Volleyball
Activites – Sports Camps:
Off-Premises Activities (describe):
Describe how participants are transported to off-premises locations:
On-Premises Activities (describe):
Accreditation and Associations:
A.C.A.
Association Member If yes, name of association(s): __________________________________________
Overnight:
Overnight exposures If yes, provide details:
Premises:
Premises are leased
Premises are owned by applicant
Bleachers
Playing fields (baseball, softball) If yes, number of playing fields: _______
Courts (basketball, tennis or volleyball) If yes, number of courts: ______
Ranges (archery) If yes, number of archery ranges: ______
Running track If yes, length of running track: ______
Sports equipment owned by insured and stored on premises (i.e. nets, goals and similar)
Risk Transfer:
Accident and Health coverage is provided for participants by the applicant. If yes provide name of Carrier and
Limits of Liability: _______________________________________________________________________
Contract with all participants includes a ‘hold harmless’ clause
SUBCONTRACTORS / INDEPENDENT CONTRACTORS
Uninsured subcontractors are not acceptable.
Risk Transfer – Subcontractors:
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of insurance - Always obtained from a subcontractor prior to any work being done for you.
C‐APP038‐0815 Page3of4
SPORTS CAMPS, CLINICS AND LEAGUES - SUPPLEMENTAL APPLICATION
EMPLOYEES
Number of employees (included leased employees): __________
Ratio of counselors/supervisors to participants is: 1 to _______ participants
CPR – at least one trained employee on duty at all times
RATING / PREMIUM BASIS – SPORTS CLINICS OR SPORTS LEAGUES
Clinics - Number of participants
Clinics - Number of days
Sports Leagues - Number of games per season
Number of traveling tournaments
RATING / PREMIUM BASIS – SPORTS CAMPS
Number of participants per day (estimated)
Number of days per week
Number of weeks per year
PLANNED EXPANSION OR NEW ACTIVITIES IN COMING POLICY TERM
New activities or expansion is anticipated (describe):
COVERAGE OPTIONS - LIABILITY (check if you would like a quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like a quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement:
Bronze – U777C Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
C‐APP038‐0815 Page4of4
SPORTS CAMPS, CLINICS AND LEAGUES - SUPPLEMENTAL APPLICATION
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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