Amateur Sports Associationinsurance Application

AMATEUR SPORTS ASSOCIATIONINSURANCE APPLICATION

BROKER INFORMATION

Broker/Agency Name:
Contact Person:
Address:
City / State / Zip
Phone: / Fax:
E-mail Address: / Website:
GENERAL INFORMATION
1.Name of Insured (as it will appear on the policy):
2.Location of Headquarters:
(Street) / (City) / (State) / (Zip)
3. Telephone Number: / Fax: / Website:
4.Form of Business: / Corporation Joint Venture Partnership LLC
Other (please describe):
5.Is the insured considered: For Profit Not-for-profit organization / Federal ID #:
6.Date of Incorporation: / Chartered or Incorporated in What State?
7.Name of Officers: / President: / Executive Director:
Insurance Chairman: / Risk Manager:

1. Please provide detail on management experience:

1. Nature of operations/description of the insured:

10.Does the insured engage in any other business operations under the name of the insured as it will appear on the policy? Yes No If yes, please explain:

1. Proposed Effective Date:

1. Are local, state and regional organizations involved in your organization? Yes No

If yes, please explain:
13.Is insurance to be extended to these groups on a blanket basis? Yes No
14.Is participation in the insurance program Mandatory Optional
If optional, please explain:
15.What activities are sanctioned by the insured?
16.Explain the sanctioning procedures:
17.In order to take part in a sanctioned event the insured requires:
100% membership in order to compete in an event
100% membership in order to compete in an event but will allow trial memberships
Insured opens competitions to non-members
18.Please list all Additional Insureds and their relationship to the Named Insured:
Additional Insureds / Relationship to Named Insured
19.Number of Participants in this association: / Number of Minor Participants:
Number of sanctioned events per year: / Number of coaches:
Number of officials/umpires: / Number of Volunteers:
Number of clubs/teams:

1. Please list all events conducted by the association at which anticipated attendance will exceed 20,000 people:

Event / Location / Date / Est. Attendance
21.Coverage Requested / Limit Requested / Limit Required
Per Occurrence: / Retention:
General Aggregate:
Participant Legal Liability:
Personal & Advertising Injury:
Damage to Premises Rented to You:
Products/Comp. Ops Liability:
22.Please describe participant personal accident coverage provided for your association:
Carrier: / Primary Excess
Accident Limits: / Accidental Death & Dismemberment limits: $
Catastrophic Limits:

PAST INSURANCE EXPERIENCE

23.Do you presently carry insurance of this type? Yes No
If yes, with which insurer?
24.Has any insurer ever canceled or refused coverage? Yes No
If yes, explain:
25.Insurance Experience information for Past Five Years:
Carrier
Year
Premium / $ / $ / $ / $ / $
Total Insured Claims (Paid & Reserved) / $ / $ / $ / $ / $
26.Description of any individual claim or reserve in excess $10,000:

UNDERWRITING

27.Does the insured promulgate sports rules? Yes No
If yes, please provide a copy of the rules and/or the website link where available.
28.Does the insured have any international exposure? Yes No
If yes, please explain:
29.Are the insured’s members subject to drug testing? Yes No
If yes, what entity conducts the drug testing:
30.Is there a formal officials and/or coaches instruction program? Yes No
If yes, please provide copies of all written material in the program.
31.Does the insured employ a risk manager? Yes No
32.Does the association have a formal athlete injury control program Yes No
If yes, please provide a copy of this program.
33. Do you currently secure waiver and release and/or assumption of risk statements from all participants?
Yes No
If yes, please provide a copy of each such document.
a.Who signs the waivers? (e.g. all athletes):
b.When are the waivers signed? (e.g. at membership inception and prior to each event):
c.How long are the waivers kept? (e.g. statutory):
d.Where are the waivers stored? (e.g. warehouse)

1. Please describe the preparations the association takes for potential athlete injuries during competition and practice:

35.Does the Association have a method of reviewing contracts entered into by its member team/club, if applicable?
Yes No
If yes, please describe:
36.Please describe how information is disseminated from the national level to the individual team/club (i.e. rule changes):
37.Does the Association have a method for ensuring the safety and adequacy of competition areas? Yes No of spectator areas? Yes No
If yes, please describe:
38.Are all competition areas in compliance with state and local codes? Yes No
If no, please explain:
A.ABUSE AND MOLESTATION
(Please complete this section if you need a quote for Abuse and Molestation Coverage. If you do not need a quote for Abuse and Molestation Coverage please skip this section and continue to the next section.)
39.Does the insured have custodial responsibility for minors? Yes No
If yes, is abuse coverage desired? Yes No
40. Do your employees and volunteers (paid and volunteer) employment application include questions about whether the individual has ever been convicted for any crime, including sex-related or child-abuse offenses?
Yes No
If yes, what is the process for dealing with a "yes" answer?
41.(a)Does your state permit you to do criminal background checks on:
Yes No Employees?
Yes NoVolunteers?
(b)If yes, do you routinely request and receive such background information on all individuals who will have contact with minors? Yes No
42.(a)Do you verify employment-related references for employees? Yes No
(b)Do you verify employment-related references for volunteers? Yes No
43.(a)Do you conduct a personal interview for employees? Yes No
(b)Do you conduct a personal interview for volunteers? Yes No
44.Do you have a written set of procedures for screening employees and volunteers? Yes No
If yes, please forward. If no, please describe your screening process.
45.Do you have an Abuse / Molestation Policy with regard to sexual abuse? Yes No
If yes, please indicate how it is provided to your employees/volunteers.
46.Do you have written procedures for dealing with allegations of sexual abuse? Yes No
If yes, please forward. If no, please describe what your current response would be.
47.Describe how your organization supervises employees and volunteers having custody of children.
48.Describe specific policy regarding any overnight travel.
49.(a) Has your organization ever had an incident which resulted in an allegation of sexual abuse? Yes No
If yes, please describe your organization's response to the allegation.
(b) Was a claim made against the organization or an individual within the organization? Yes No
When did the alleged incident(s) occur?
(c) Was the case taken to trial? Yes No / Civil Criminal
(d) What was the disposition of the case?
50.Regarding coverage for abuse and molestation, does your current insurance program:
Yes NoExclude coverage?
Yes NoLimit coverage (please forward a copy of the endorsement)?
Yes NoNeither exclude or limit coverage?
51.Please indicate age range of minors in your care or under the supervision of your employees or volunteers at any time.
52.Please describe your current and/or planned operations that involve the custodial care of minors.

B.LIQUOR LIABILITY

(Please complete this section if you need a quote for Liquor Liability Coverage(fundraisers, etc.). If you do not need a quote for Liquor Liability,please skip this section and continue to the next section.)

53.Name on liquor license:
54.Liquor license number: / Class of license:
55. Type of facility or event where liquor will be sold:
Dates coverage required:
Opening and closing hours of event(s):
Opening and closing hours of liquor sales:
56.Has applicant's liquor license ever been revoked or suspended? Yes No
If yes, please explain:
57.Has applicant incurred claims for liquor liability during the last 3 years? Yes No
If yes, please explain:
58.Has any insurer cancelled or non-renewed coverage during the last 3 years? Yes No
If yes, please explain:
59.Has applicant ever been fined by alcoholic beverage control or other governmental regulator? Yes No
If yes, please explain:
60.Type of beverages sold:
61.Annual Gross Sales:
Liquor Sales $
Food Sales$
Other$
62.Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If yes, what type?
63.Do you exercise the right of search and seizure of contraband items? Yes No
If yes, how do you notify the public of this?
64.Do you maintain security personnel at entry check points? Yes No
If yes, what type?
65.Are the alcohol sales and consumption: Contained within one fixed site, or Are booths/stands located throughout the event site?
66.Number of servers used?
Professional? Yes No Explain:
Volunteer? Yes No Explain:
67.Do the servers receive any type of alcohol awareness training? Yes No
If yes, please explain:
68.Median age of liquor customers: 21-25 25-30 30-40 40 and over
Are minors allowed to enter the location where alcohol is being served? Yes No
If yes, how is underage consumption of alcohol prevented?
69.Explain how ID's are checked:
70.Are uniformed police officers present at the site of alcohol sales? Yes No
If yes, how many?
Are undercover police officers present? Yes No
If yes, how many?
Are private security officers present? Yes No
If yes, how many?
71.Are rules and regulations clearly displayed for patrons viewing? Yes No
Describe:
72.In what size of container is the alcoholic beverage served? Cup oz. Pitcher
Other
73.Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No
Explain:
74. Is there entertainment provided? Yes No
Live music? Yes No
Disc Jockey? Yes No
Type of music:
75.Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No
Explain:
76.Is there any type of designated driver program? Yes No
Explain:
77.Is there any other underlying liquor liability coverage being provided? Yes No
Explain:
78.Will there be additional limits of liquor liability purchased? Yes No
If yes, what is the additional limit?

C.PYROTECHNICS

(Please complete this section if you need a quote for Pyrotechnics Coverage (scoreboard fireworks, etc.). If you do not need a quote for Pyrotechnics, pleaseskip this section and continue to the next section.)

79.Limit of liability requested: $1,000,000 Other:
80.Description of Events:
81.Location of Events:
Street / City / State / Zip
82.Dates of Events:
83.Who is the Authority having jurisdiction over the use of pyrotechnics at your facility?
Local Fire Department State Fire Marshal Other (please list):
84.What permit process must be followed prior to use of pyrotechnics at your facility:
85.Have you staged pyrotechnic displays before? Yes No
If yes, please list any claims/losses that have occurred and the amount of loss:
Description / Date of Occurrence / Amount of Loss
A.
B.
C.
86.Who will be the pyrotechnics operator?: Named Insured Contractor
Complete this section if thePyrotechnics Operator is the Named Insured
(a) List names of people shooting fireworks and describe their experience.
Please note: This coverage will exclude Bodily Injury Liability to the fireworks shooter.
Name / Experience
(b)Where are the pyrotechnics stored when not in use?
Does it meet Federal/State Storage Regulation? Yes No
What quantity of pyrotechnic material is stored on site (pounds, # of shows, etc):
Describe the type and amount of pyrotechnics used in recurring events (e.g. facility introductions, home runs, etc.):
Describe what fire prevention and suppression measures are taken to support the pyrotechnic loading and firing
process:
Do you secure proper pyrotechnic permits for each event? Yes No
Are the shooters listed above licensed for pyrotechnics? Yes No
Complete this section if thePyrotechnics Operator is a Contractor.
(a)Name:
(b)Is there an agreement with the contractor? Yes No
If yes, please provide a copy of the agreement.
(c)Will liability coverage be provided by the pyrotechnics contractor? Yes No
If yes, please indicate limits of coverage provided:
$1,000,000 Greater than $1,000,000 Other:
Please attach a copy of certificate of insurance including any additional insured listing
(d)Do you confirm that the contractor has secured the proper pyrotechnic permits for each event?
Yes No
(e) Describe what fire prevention and suppression measures are taken to support the pyrotechnic loading and firing process:
(6)
87.87.Do you allow tenant users (including temporary tenant users) to conduct pyrotechnic displays either themselves or through a contractor? Yes No
If yes, what steps are taken to ensure that the appropriate permits are granted, appropriate fire safety codes are
met, and that insurance has been obtained from either the tenant or the tenant’s contractor which lists you as an
Additional insured?
If no, does the tenant lease/use agreement indicate that pyrotechnic displays are not permitted? Yes No
88.Are events with pyrotechnics held: Indoors Outdoors
89.What type of pyrotechnics will be displayed (as defined in NFPA code 1126)?
Aerial Shells Airbursts Black Powder Comets
Concussion Effects Concussion Mortars Electric Matches Flares
Flash Pots Flashpowder Gerbs Integral Mortars
Mines Mortars Rockets Saxons
Waterfall, Falls, Park Curtains Wheels Salutes
Other, please list:
OUTDOOR PYROTECHNICS (only complete if outdoor pyrotechnic displays are staged)
90.Are the events in compliance with NFPA 1123 or 1126 (Code for Fireworks Display)? Yes No
91.Is there fencing to keep spectators away from restricted areas during the fireworks shooting? Yes No
If yes, distance of spectator fencing from launch site:
Distance of spectator parking area from launch site:
Distance of closest building or structure from launch site:
92.Will there be firefighting equipment on site during the event? Yes No
93.If no firefighting equipment on site, give distance to nearest fire station:
94.Will you have an ambulance on site? Yes No
If no,(a) what is the estimated response time of an ambulance?
(b) distance to nearest medical facility:
INDOOR PYROTECHNICS (only complete if indoor pyrotechnic displays are staged)
95.Are the events in compliance with NFPA 1126 (Standard Code for the Use of Pyrotechnics before a Proximate Audience)? Yes No
96.Is the facility sprinklered? Yes No
97.What other form of fire fighting equipment is available at the facility?
98.Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
99.Number of accessible (not locked) emergency exits at the facility:
100.What steps are taken to inform patrons of the locations of all emergency exits?
101.Maximum capacity of the facility:
102.Has the fire marshal approved the use of pyrotechnics at the facility? Yes No
If yes, as of what date:

D.NON-OWNED AND HIRED AUTO LIABILITY

(Please complete this section if you need a quote for Non-Owned and Hired Auto Coverage. If you do not need a quote for Non- Owned and Hired Auto, please skip this section and continue to the next section.)

103.Does the Insured have any owned automobiles? Yes No
If yes, who is the insurer?
Limits of coverage: / Effective date of coverage:
104. Do you allow employees to use their own personal vehicles for your business purposes? Yes No
If yes, how many employees use their own personal vehicles?
If yes, how often? Daily Weekly Monthly Other
105.Do you have a driver screening program for those employees who use their own personal vehicles for your business purposes? Yes No
106.Do you obtain Motor Vehicle Reports? Yes No
If yes, how often? Annually Every other year Other
107.Do you confirm that all employees who regularly use their cars for business purposes carry minimum personal auto limits? Yes No
If yes, what minimum limits are required?
108. Please provide the approximate cost of hire for all hired or leased autos during the
course of the policy period: $
109. Do you have a driver training program for employees who use owned vehicles or their own personal vehicles?
Yes No
110.Limits of coverage required: $100,000 $300,000 $500,000 $1,000,000 Other
111.Is hired auto physical damage required? Yes No
If yes, what is the maximum value of hired vehicle you would like insured? $
What deductible level would you like? $250 $500 $1,000 Other

E.EMPLOYEE BENEFITS LIABILITY

(Please complete this section if you need a quote for Employee Benefits Liability Coverage. If you do not need a quote for Employee Benefits Liability, please skip this section and continue to the next section.)

112.Does applicant have a full-time Personnel Department? Yes No
113.Number of employees under Employee Benefit Program administered in the U.S. or Canada:
114.Employee Benefit Programs which are automatically covered without being specifically listed by the applicant are (check all that apply):
Group Life Insurance / Group Accident or Health Insurance / Profit Sharing Plans / Pension Plans
Employee Stock Subscription Plans / Workers' Compensation / Unemployment Insurance
Disability Benefits Insurance / Social Security Benefits
115.List below any other types of benefit programs the applicant wants the company to consider for inclusion under this insurance:
Type of Benefit Program
116.On programs permitting employees an option to enroll or not to enroll, does the applicant require a signed acceptance or rejection from each employee? Yes No
If yes, is the signed acceptance or rejection retained in the employee's personnel file? Yes No
117.Is a benefit brochure or written explanation of the Employee Benefits Program given to each employee? Yes No
118.Are all benefits available to all employees? Yes No
If no, list all exceptions:
119.Who advises the employees of their benefits?
Personnel Manager / Department Manager / Immediate Supervisor / Other (Please describe):
120.Is there a review of employee questions and a record kept as to each employee's acceptance or rejection of any one or all the benefits? Yes No
121.Has any Error and Omission loss ever been sustained or is any such claim pending against the applicant? Yes No
If yes, please give details:
122.Has any occurrence taken place in the past that is likely to give rise to a claim? Yes No
If yes, please give details:
123.Number of branches, other business locations:
124.How are employees in branches and other locations advised of benefits?
125.What is the first date any previous Employee Benefits Liability coverage was carried?

Please provide the following with this application:

• Five years of company loss runs for all requested coverages.
• Most current audited financials.
• Copy of all expiring policies or specific manuscript endorsements that the insured would like to submit for consideration.
• A list of all locations to be insured, including addresses and descriptions of each.

• A list of all insureds to be included along with a description of each.

• A list and description of any ancillary activities to be covered.
• If the application for coverage is for an event or multiple events, provide a copy of all brochures describing the event(s).
• Copies of subcontractor agreements or agreements between the insured and any additional insured, including a list of all additional insured.
• Copies of certificate of insurance naming the association as an additional insured if liquor or pyrotechnics coverage has been requested.
• A copy of all rule books and association manuals.
• A copy of the association’s formal officials and/or coaches instruction program.
• A copy of the association’s formal athlete injury control program.
• A copy of the association’s written procedures for screening employees and volunteers if applicable.
• A copy of the association’s written procedures for dealing with allegations of sexual abuse if applicable.
• A copy of waiver and release and/or assumption of risk statements.

If the following coverages are required, please complete ACORD apps: