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CAMP S
UPPLEMENT
If none, check here.
Named Insured: _____________________ Policy No. If Renewal ___________
_____________________
1. The camp is operated from _________ to _________. Camp Receipts __________
Month/Date Month/Date
2. The hours of the camp are from _______ to ______, ______ days per week.
3. Are overnight accommodations provided? Y N
4. Are meals prepared and/or provided by you? Y N
5. Ages of campers? _________.
6. Are there any campers who are physically or emotionally handicapped? Y N
7. Number of campers per day per week. ______/______.
8. Number of campers that are not regular students per day per week _____ / _____.
9. Number of adult supervisors? ______
10. There are _____ supervisors under the age of 18.
11. What are the ages of the counselors? _____. What type of training do they receive?
___________________________________________________________________
12. Is any camp counselor/employee/supervisor under investigation for, or has a previous
record of, child abuse? Y N
13. How are medications kept and distributed to children with prescription/non-
prescription needs? Y N
14. Campers are under adult supervision at all times. If children are not in the direct
vision of adults, are adults aware of where they are and what they are doing? Y N
15. All equipment and buildings are maintained in a safe, clean condition and in good
repair. Indoor and outdoor environments are safe, clean and spacious. Y N
16. Is there a swimming pool? Y N If the answer is yes, answer the following.
Is the pool fenced? Y N Depth ______. Is there a diving board? Y N
Is there a lifeguard on duty? Y N
What type of certification is required of the lifeguard?_____________________
Are swimming lessons given? Y N
What type of certification is required of the instructor? ____________________
17. There are ____fire extinguishers in the buildings in which the campers will be
conducting activities.
18. All poisonous/toxic materials are kept under lock and key and out of children’s
reach. Y N
19. Detail all camp activities ____________________________________________
__________________________________________________________________
20. Are there any off premises activities? Y N
If yes, describe in detail _______________________________________________
___________________________________________________________________
21. Do you provide transportation to campers for any reason? Y N
If yes, we will require a COI from your auto carrier and complete driver
information of all drivers.
Insured’s Signature: __________________________________Date: ______________
Agent’s Signature: __________________________________Date: ______________
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Completed 30 July 2020

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