Fillable Sports Camps/Clinics/Leagues General Liability Application (RT Specialty)

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Sports Camps/Clinics/Leagues General Liability Application (RT Specialty)

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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
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Sports Camps/Clinics/Leagues General Liability Application
Applicant’s Name:
Mailing Address:
Location Address:
Web site Address:
Agency Name:
Agent:
Address:
E-Mail:
Phone:
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”
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify)
Limits Of Liability & Deductible Requested:
General Aggregate (other than Products/Completed Operations) $
Products & Completed Operations Aggregate $
Personal & 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 $
GLS-APP-40s (8-12) Page 1 of 7
Submit Application
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
GLS-APP-40s (8-12) Page 2 of 7
8. Any fund-raising events held that applicant sponsors? .................................................................. Yes No
If yes: Bake sales Car washes Other (describe):
9. 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:
10. 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:
11. Does applicant have other business ventures for which coverage is not requested? ................ Yes No
If yes, explain and advise where insured:
12. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Coverage
Policy No.
Total Premium
13. 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
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?
GLS-APP-40s (8-12) Page 3 of 7
9. Total number of campers days (Total number of “camper days” shall be the sum of the daily number 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 College athletes camp ..................... Yes No
Other than sports camp ........................ Yes No Outward bound program ................. Yes No
Professional athletes camp ................... Yes No Resident camp ................................ Yes No
Tough love camp .................................. Yes No Travel camp..................................... 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:
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:
GLS-APP-40s (8-12) Page 4 of 7
24. Does applicant have a brochure and/or advertising material? ....................................................... Yes No
If yes, please attach.
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. League or clinic is for: Boys Girls Adults College Athletes Professional Athletes
15. Indicate all sports/activities played or instructed:
Archery Baseball Basketball Bowling
Boxing Cheerleading Cross country hiking Diving
Football (flag) Football (tackle) Golf Gymnastics
Hang gliding Hockey Lacrosse Polo
Rappelling Roller derby Rugby Running
Scuba diving Skateboarding Sky diving Snow skiing/boarding
Soccer Softball Squash Surf
Swimming Tennis Volleyball Water skiing/boarding
Wrestling Other:
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?
GLS-APP-40s (8-12) Page 5 of 7
17. Any hold harmless agreements? ....................................................................................................... Yes No
If yes, whom and what is the nature of the agreement?
18. 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:
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 Nebraska, Oregon and Vermont.
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.
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
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
GLS-APP-40s (8-12) Page 6 of 7
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony in the third degree.
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 and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and 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 knowingly and with intent to defraud any insurance company 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.
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 Tennessee, Virginia and Washington): It is a crime to knowingly provide false, in-
complete or misleading information to an insurance company for the purpose of defrauding the company. Penalties in-
clude imprisonment, fines and denial of insurance benefits.
NOTICE TO NEW YORK APPLICANTS (Other than automobile): 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 authorized owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
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.
GLS-APP-40s (8-12) Page 7 of 7
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Completed 13 December 2020

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