Fillable SPORTS CAMPS/CLINICS/LEAGUES GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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SPORTS CAMPS/CLINICS/LEAGUES GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-40s (7-18) Page 1 of 8
SPORTS CAMPS/CLINICS/LEAGUES GENERAL LIABILITY APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Website Address:
E-mail Address: Phone No.:
Limits Of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations) $
Products and Completed Operations Aggregate $
Personal and Advertising Injury (any one person or organization) $
Each Occurrence $
Damage To Premises Rented To You (any one premise) $
Medical Expense (any one person) $
Limited Participant Coverage $25,000/$50,000 (included)
Sexual and/or Physical Abuse Coverage $25,000/$50,000 (included)
Other Coverages, Restrictions and/or Endorsements:
$
Deductible $
GL-APP-40s (7-18) Page 2 of 8
A. GENERAL INFORMATION:
1. Operation is: Camp Clinic League
2. Does applicant have any operations as a sports scout, agent or booking agency? ................... Yes No
If yes, advise:
3. Any previous or pending allegations of sexual and/or physical abuse? ...................................... Yes No
If yes, explain:
4. Is there a swimming pool or other bodies of water where swimming is permitted? ................... Yes No
If yes:
a. Number of pools: ............................................................................................................................
b. Describe other bodies of water:
c. Pool area fenced with self-latching gate? ....................................................................................... Yes No
d. Depths marked? ............................................................................................................................. Yes No
e. Rules posted? ................................................................................................................................. Yes No
f. Life safety equipment at poolside and/or waterfront?..................................................................... Yes No
g. Platforms or diving boards? ........................................................ Yes No Height:
h. Slides? ........................................................................................ Yes No Height:
i. Lifeguards? ..................................................................................................................................... Yes No
(1) If yes, by applicant or outside contractor?
If outside contractor, are certificates of insurance on file?....................................................... Yes No
(2) Are lifeguards Red Cross certified? ......................................................................................... Yes No
j. Ratio of attendants to children while swimming: ............................................................................
k. Swimming pools, wading pools, hot tubs and spas in compliance with the federal Virginia
Graeme Baker Pool and Spa Safety Act? ...................................................................................... Yes No
5. Are staff members trained in CPR? .................................................................................................. Yes No
Is a CPR trained staff member on duty at all times? ............................................................................ Yes No
6. Does applicant subcontract any operations? .................................................................................. Yes No
If yes:
a. Description of operations subcontracted:
b. Annual cost of subcontracted work:
c. Are all subcontractors required to carry General Liability and Workers Compensation
Insurance? ...................................................................................................................................... Yes No
If yes, minimum General Liability limits required:
d. Are certificates of insurance required from all subcontractors? ..................................................... Yes No
e. Is applicant included as an additional insured on all subcontractors’ policies? ............................. Yes No
f. Do written contracts contain hold-harmless agreements in favor of the applicant? ....................... Yes No
7. Additional Insured Information:
Name Address Interest
GL-APP-40s (7-18) Page 3 of 8
8. Any fund-raising events held that applicant sponsors? ................................................................. Yes No
If yes: Bake sales Car washes Other (describe):
9. Does applicant have a brochure and/or advertising material? ...................................................... Yes No
If yes, please attach.
10. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies? ............................................................................................. Yes No
If yes, describe:
11. During the past three years, has any company ever canceled, declined or refused similar in-
surance to the applicant? (Not applicable in Missouri) ...................................................................... Yes No
If yes, explain:
12. Does applicant have other business ventures for which coverage is not requested? ............... Yes No
If yes, explain and advise where insured:
13. Prior Carrier Information:
Year: Year: Year: Year: Year:
Carrier
Coverage
Policy No.
Total Premium $ $ $ $ $
14. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may
give rise to claims for the prior five years. Check if no losses last five years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or Closed)
$ $
$ $
$ $
$ $
$ $
B. SPORTS CAMPS QUESTIONNAIRE (see SECTION C. for Youth Leagues and Clinics)
1. Name of camp (if different than applicant):
2. List all sports included:
3. Will campers stay overnight? ............................................................................................................ Yes No
If no, advise when Day Camp opens: Advise when Day Camp closes:
4. Years in business: ..............................................................................................................................
Years under present ownership: ...........................................................................................................
5. Is camp accredited by A.C.A. (American Camp Association)? .......................................................... Yes No
GL-APP-40s (7-18) Page 4 of 8
6. Is camp a member of another camping association? ..................................................................... Yes No
If yes, which one(s)?
7. Estimated number of campers per day: ...........................................................................................
8. How many days per week is camp operated? .................................................................................
How many weeks per year? ..................................................................................................................
9. Total number of camper days (Total number of “camper days” shall be the sum of the daily num-
ber of campers for each day the camp is in operation during the policy period): .................................
10. Camp is for: Boys Girls Adults
11. Camp is a:
Boot camp ............................................. Yes No Professional athletes camp .............. Yes No
Cheerleading camp ............................... Yes No Resident camp ................................. Yes No
College athletes camp .......................... Yes No Tough love camp .............................. Yes No
Other than sports camp ........................ Yes No Travel camp ..................................... Yes No
Outward bound program ....................... Yes No Wilderness/Survival camp ................ Yes No
12. Camp is operated by: Private Organization Nonprofit Organization Religious Organization
13. Age range of campers: .......................................................................................................................
14. Total number of employees: ..............................................................................................................
15. Ratio of counselors to campers: .......................................................................................................
16. Does the applicant have accident and health coverage on the campers? ................................... Yes No
If yes, who is the carrier and what are the limits of liability?
17. Any hold harmless agreements? ...................................................................................................... Yes No
If yes, with whom and what is the nature of the agreement?
18. Does the camp specialize in camping experiences for developmentally disabled individuals? Yes No
If yes, provide a narrative of such program below or on a separate sheet, if necessary:
19. List the locations of the facilities where the camps are being held:
20. Describe all activities the campers will be involved in during the duration of their stay:
a. Will campers ride horses? .............................................................................................................. Yes No
b. Are there snowmobiles for campers’ use? ..................................................................................... Yes No
21. Are there motorized watercraft? ........................................................................................................ Yes No
If yes, advise how many and describe:
GL-APP-40s (7-18) Page 5 of 8
22. Are there boats in excess of twenty-six (26) feet in length or that have motors over seventy-
five (75) HP? ........................................................................................................................................ Yes No
If yes, how many? .................................................................................................................................
23. If the campers are participating in activities away from the camp, what is the mode of transportation and
what arrangements are made to transport the participants?
If applicant transports participants, advise name of auto carrier and limits:
If the questions for SECTION C. YOUTH LEAGUES AND CLINICS do not apply, please turn to the last page, read
the fraud warnings, sign and date the application.
C. YOUTH LEAGUES AND CLINICS QUESTIONNAIRE (see SECTION B. for Sports Camps)
1. Name of the league or clinic (if different than applicant):
2. Any overnight stays? .......................................................................................................................... Yes No
3. Name and address of the sponsor:
4. Is the premises or playing field owned by the applicant? .............................................................. Yes No
If yes, what is the size and use of the premises, number of fields and owned equipment on the premises?
(Example: bleachers, nets, courts and goals):
5. Years in business: ..............................................................................................................................
6. Total number of employees: ..............................................................................................................
7. Number of clinic participants: ...........................................................................................................
Number of days for the clinic:................................................................................................................
8. Total number of games for the sports league for the season: .......................................................
9. Age range of the participants: ...........................................................................................................
10. Number of coaches: ............................................................................................................................
If accredited, by whom?
11. Ratio of supervisors to participants: ................................................................................................
12. Do coaches carry their own insurance? ........................................................................................... Yes No
If yes, who is the carrier and what are the limits of liability?
13. Is league or clinic a member of an association? ............................................................................. Yes No
If yes, which one(s)?
14. Does the clinic or league specialize in workshops or games for developmentally disabled
individuals? ......................................................................................................................................... Yes No
If yes, please provide details of program below or on a separate sheet, if necessary:
15. Any hold harmless agreements? ...................................................................................................... Yes No
If yes, whom and what is the nature of the agreement?
GL-APP-40s (7-18) Page 6 of 8
16. League or clinic is for: Boys Girls Adults College Athletes Professional Athletes
17. Indicate all sports/activities played or instructed:
Archery Baseball Basketball Bowling
Boxing Bubble Soccer Cheerleading Cross country hiking
Diving Football (flag) Football (tackle) Golf
Gymnastics Hang gliding Hockey Lacrosse
Polo Rappelling Roller derby Rugby
Running Scuba diving Skateboarding Skydiving
Snow skiing/boarding Soccer Softball Squash
Surf Swimming Tennis Volleyball
Water skiing/boarding Wrestling Other:
18. Does the applicant have accident and health coverage on the campers? ................................... Yes No
If yes, who is the carrier and what are the limits of liability?
19. Does applicant participate in traveling tournaments? .................................................................... Yes No
If yes:
a. How many? .....................................................................................................................................
b. What is the mode of transportation and what arrangements are made to transport the participants?
c. If applicant transports participants, advise name of auto carrier:
20. List what safety equipment is required to be worn by the participants and are they advised to its proper
use:
21. List the locations of the facilities where the games/clinics are being held:
22. Does applicant have a snack bar, sports shop or other retail business? .................................... Yes No
If yes, describe and indicate the estimated gross sales:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
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.
GL-APP-40s (7-18) Page 7 of 8
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
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 fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 state-
ment 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 un-
der 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.
GL-APP-40s (7-18) Page 8 of 8
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 STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
Agent Email: Preferred Method of Correspondence Email Fax Mail
Applicant Email: Preferred Method of Correspondence Email Fax Mail
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SPORTS CAMPSCLINICSLEAGUES GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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