DOG TRACK LIABILITY

INSURANCE APPLICATION

BROKER INFORMATION

Broker/Agency Name:
Contact Person:
Address:
City / State / Zip
Phone: / Fax:
E-mail Address: / Website:

GENERAL INFORMATION

1.Name of proposed insured:
(As it is to appear on policy.)
Track Location:
Street / City / State / Zip
Mailing Address:
Street / City / State / Zip
2.Name of contact: / Title:
Mailing Address:
Street / City / State / Zip
Phone: / Fax:
E-Mail Address: / Website:
3.Form of business: / Corporation / Partnership / Joint Venture / LLC / Other:
4.Does the insured engage in any other business operations under the name shown above? Yes No
If yes, explain:
5.Proposed effective date:
6.Do you own or lease the facility? Own Lease
If leased, please provide a copy of current lease agreement.
7.Number of years the current management has operated the track and details of management experience:
8.Does the track employ a risk manager? Yes No
9. / Coverage Requested / Limit Requested / Retention
Primary General Liability / $ / $ per occurrence
Personal/Advertising Injury / $
Products/Completed Ops / $
General Aggregate / $
Dog Legal Liability / $ per dog / $ aggregate
10.Has any insurer ever canceled or refused coverage? Yes No
If yes, please explain:
11.General liability loss information for the last five years:
YEAR / PREMIUM / INCURRED LOSSES
Please describe any claim or reserve in excess of $10,000:
12.Who is responsible for the following operations?
Parking / Insured / Subcontracted / N/A / Describe:
Security / Insured / Subcontracted / N/A / Describe:
Maintenance / Insured / Subcontracted / N/A / Describe:
Concessions / Insured / Subcontracted / N/A / Describe:
Liquor / Insured / Subcontracted / N/A / Describe:
First Aid / Insured / Subcontracted / N/A / Describe:
Fireworks / Insured / Subcontracted / N/A / Describe:
* Supplemental application required if coverage is desired (either primary or contingent)
Do all subcontractors carry liability limits at least equal to $1,000,000? Yes No
Is facility listed as an additional insured, indemnified and held harmless? Yes No
Please provide copies of all applicable contracts/agreements and certificates of insurance.
13.Live race dates: / through
Total number of days:
Simulcast dates:
Total number of days:
14.Estimated annual attendance: / Live: / Simulcast:
Average daily attendance: / Live: / Simulcast:
15.Do you own or operate any off track betting locations? Yes No
Address:
Street / City / State / Zip
Annual Admissions: / Annual Receipts:
16.Do you have slot machines? Yes No
If yes, how many?
Do you have other gaming devices? Yes No
Explain:
Estimated annual casino admissions:
Annual employee payroll for casino exposure?
17.Do you hold non-racing events at your facility (concerts, festivals, car shows, trade shows, flea markets, etc.)? Yes No
If yes, please describe:
Event / Date(s) or # of Days / Total Admissions / Track sponsored or Third Party
A.
B.
C.
For events conducted by third parties, are certificates of insurance collected that name the facility as an additional insured? Yes No
Please provide a copy of the facility rental agreement required for special events.
18.Are any constructions projects planned for the coming year? Yes No
If yes, explain:
19.Please complete the following:
Total Annual Receipts
A. Admissions:
B. Restaurant:
C. Liquor:
D. Merchandise:
E. Parking:
F. Attractions:
G. Non-Dog Racing Events:
H. Casino/Slots:
20.Do you provide dormitory or other accommodations for track employees? Yes No
Please provide a copy of the dormitory or accommodation agreement.
Are grounds completely fenced? Yes No
If no, explain:
21. / Total grandstand capacity: / Year built: / Type of construction:
Total clubhouse capacity: / Year built: / Type of construction:
Total bleacher capacity: / Year built: / Type of construction:
22.What percentage of grandstand/clubhouse is sprinkled?
Are fire extinguishers easily accessible in all buildings? Yes No
What is the distance to the nearest fire station?
23.Does your track offer greyhound adoption services? Yes No
24.Are there any playgrounds/campgrounds/amusement areas on site for which coverage is desired?
Yes No
If yes, please explain:
25.How many restaurants/concession areas/bars do you operate?
Describe:
26.Is a log kept of inspections completed and maintenance performed throughout the facility? Yes No
27.Medical Services
Do you have on-site medical assistance? Yes No
Number of the following on-site:
Doctors: / Nurses: / EMTs:
Ambulances: / First Aid Stations:
Does the track employ any EMTs or other medical providers? Yes No
If yes, please explain:
28.Dog Legal Liability
# of kennels: / # of dogs kenneled:
Please indicate the construction of kennels (frame, joisted masonry, masonry non-combustible, fire resistive, etc.):
What percentage of kennels are sprinkled? %
Please indicate fire protection available (fire extinguishers, hydrants, central station alarm, security personnel, video surveillance, etc.):
How often is track inspected?
Has track been found liable for injury to or death of any dogs in the past 5 years? Yes No
If yes, explain:
Are kennels maintained during off season? Yes No
Are employed veterinarians on site during races? Yes No
Please attach a copy of the current Kennel Agreement.
How are spectators prevented from entering the kennel area?
How are spectators prevented from entering the track area?
29.Patron Services
Are buses or trams used on premises? Yes No
Are curbs, steps and ledges highlighted? Yes No
Are grandstand/clubhouse exits clearly marked? Yes No
Are stairways and emergency exit routes equipped with emergency lighting? Yes No
30.Parking
Do you provide valet parking? Yes No
Please complete the ACORD Garagekeepers Application for coverage.
Do valet drivers complete any kind of vehicle inspection? Yes No
Explain:
Are MVRs obtained annually? Yes No
Are criminal background checks conducted? Yes No
Are any shuttle services provided for patrons? Yes No
Explain:
Are shuttle drivers required to carry a CDL? Yes No
Are MVRs obtained annually? Yes No
Are criminal background checks conducted? Yes No

A.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.)

31.Does applicant have a full-time Personnel Department? Yes No
32.Number of employees under Employee Benefit Program administered in the United States Canada
33.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
34.List below any other types of benefit programs the applicant wants the company to consider for inclusion under this insurance:
Type of Benefit Program
35.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
36.Is a benefit brochure or written explanation of the Employee Benefits Program given to each employee? Yes No
37.Are all benefits available to all employees? Yes No
If no, list all exceptions:
38.Who advises the employees of their benefits?
Personnel Manager / Department Manager / Immediate Supervisor
Other (Please describe):
39.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
40.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:
41.Has any occurrence taken place in the past that is likely to give rise to a claim? Yes No
If yes, please give details:
42.Number of branches, other business locations:
How are employees in branches and other locations advised of benefits?
43.What is the first date any previous Employee Benefits Liability coverage was carried?

B.LIQUOR LIABILITY

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

44.Name on liquor license:
45.Liquor license number: / Class of license:
46. 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:
47.Has applicant's liquor license ever been revoked or suspended? Yes No
If yes, please explain:
48.Has applicant incurred claims for liquor liability during the last 3 years? Yes No
If yes, please explain:
49.Has any insurer cancelled or non-renewed coverage during the last 3 years? Yes No
If yes, please explain:
50.Has applicant ever been fined by alcoholic beverage control or other governmental regulator? Yes No
If yes, please explain:
51.Type of beverages sold:
52.Annual Gross Sales:
Liquor Sales $
Food Sales$
Other$
53.Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If yes, what type?
54.Do you exercise the right of search and seizure of contraband items? Yes No
If yes, how do you notify the public of this?
55.Do you maintain security personnel at entry check points? Yes No
If yes, what type?
56.Are the alcohol sales and consumption:
Contained within one fixed site, or Are booths/stands located throughout the event site?
57.Number of servers used?
Professional? Yes No Explain:
Volunteer? Yes No Explain:
58.Do the servers receive any type of alcohol awareness training? Yes No
If yes, please explain:
(attach training manuals used)
59.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?
60.Explain how ID's are checked:
61.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?
62.Are rules and regulations clearly displayed for patrons viewing? Yes No
Describe:
63.In what size of container is the alcoholic beverage served? Cup oz. Pitcher Other
64.Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No
Explain:
65. Is there entertainment provided? Yes No
Live music? Yes No
Disc Jockey? Yes No
Type of music:
66.Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No
Explain:
67.Is there any type of designated driver program? Yes No
Explain:
68.Is there any other underlying liquor liability coverage being provided? Yes No
Explain:
69.Will there be additional limits of liquor liability purchased? Yes No
If yes, what is the additional limit?

C.SECURITY COVERAGE

(Complete only if security is the responsibility of the insured.)

PART I
70.Who is primarily responsible (via contract) for liability coverage for security personnel?
Insured Municipality Subcontractor
Number of security personnel on staff:
Number of security supervisors:
Number on premises:
Number off premises:
71.Do any security personnel carry a firearm as part of their equipment while on duty? Yes No
If yes, number of armed security personnel:
72.Are the security persons employed or contracted by the park? Employed Contracted
("Employed" means the individual is being paid and supervised directly by the insured. "Contract" means the existence of a written contract with another entity for security services that has insurance coverage separate from the insured's policy for security liability.)
Note:If "Employed," please answer Section B., Part I, II, III, and V.
If "Contracted," please answer Section B., Part I, II, III, IV, and V.
73. If applicable, please provide the estimated payroll for employed security persons.
74.Total maximum hours per day permitted at this and all other places of employment:
Total maximum hours per week?
75.What are the staffing guidelines per number of patrons?
76.Are the guidelines determined by: Ordinance, or Statute?
Industry standard? Yes No
Other (please describe):
PART II:
77.Is there a pre-employment screening procedure? Yes No
If yes, please describe:
78.Does the procedure include contacting previous employers over the previous five years? Yes No
79.Do you contact at least three personal references? Yes No
80.Is a psychological screening profile used? Yes No
If "yes," what type:
81.Is a criminal background check made? Yes No
If "yes," what agency is used for the criminal background check?
82.Is completion of a minimum 20 hours initial training program required before deployment? Yes No
83.Who conducts the training and what are the trainers qualifications:
84.Is a minimum of 10 hours on-site training required? Yes No
85.Is a minimum of 4 hours of annual refresher or continuing education training planned and conducted for each security employee? Yes No
86.Is each security person given a personal copy of the training/safety manual? Yes No
If "yes," has each security person given the park written acknowledgment of the policies and contents?
Yes No
NOTE: PLEASE INCLUDE A COPY OF THE MANUAL & A SAMPLE OF THE WRITTEN ACKNOWLEDGMENT.
PART III:
87.Are the security personnel in uniform? Yes No
If "yes," please describe the uniform:
NOTE: PLEASE ATTACH A PHOTOGRAPH OF ONE SECURITY PERSON IN STANDARD UNIFORM.
88.Are the security personnel identified by other than a uniform? Yes No
If "yes," please describe the identification and include an example or photograph.
89.Please indicate any equipment carried or routinely available to security personnel:
Flashlight / Type: / Size: / Construction:
HandcuffsNight Stick (Is Night Stick Police Regulation? Or Other?)
First Aid Kit (including blood borne pathogen kit)
Taser/PhaserChemicals (Mace, pepper gas)
Other:
Firearm - Caliber:.357.38.9mmOther:
Make:ColtS&WRugerOther:
Covered HolsterType:
Is AmmunitionStandardOther:
Firearm and ammunition approved and inspected by park or security company? Yes No
90.Describe capabilities of each guard for constant communications with each other, the supervisor, and park
management:
91.Are dogs used in your security operations? Yes No
If yes, please provide the type of dog(s), number, and describe duties.
PART IV:
92.Date the contracting company began business:
93.Is there a written agreement with contracting company? Yes No
If "yes," Please enclose a complete copy of the written agreement
94.Name of contracting company's liability insurance carrier:
95.Is the park an additional insured on that policy? Yes No
If "yes," please enclose a complete copy of the policy.
96.Is there an established working relationship with local law enforcement? Yes No
If "yes," please describe:
97.Please attach a copy of the contracting company's employment procedures.
98.No. of contracted security personnel: / No. of security supervisors:
99.Are there any suits or legal actions pending against the company? Yes No
If yes, please explain in detail:
100.Is there a procedure to immediately report all incidents to park? Yes No
If yes, please describe:
PART V:
101.Does the supervisor make personal contact with each security person at least once during each shift?
Yes No
If "yes," please describe:
102.Please explain all "no" answers.

D.PYROTECHNICS

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

103. Limit of liability requested: $1,000,000 Other:
104. Description of Events:
105. Location of Events:
Street / City / State / Zip
106. Dates of Events:
107.Who is the Authority having jurisdiction over the use of pyrotechnics at your facility?
Local Fire Department State Fire Marshal Other (please list):
108.What permit process must be followed prior to use of pyrotechnics at your facility:
109.Please submit the pyrotechnics plan from the most recent use of pyrotechnics for which a permit was obtained.
110.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.
111.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. 112.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
113. Are events with pyrotechnics held: Indoors Outdoors
114.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)
115.Are the events in compliance with NFPA 1123 or 1126 (Code for Fireworks Display)? Yes No
116.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:
117.Will there be firefighting equipment on site during the event? Yes No
118.If no firefighting equipment on site, give distance to nearest fire station:
119.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)
120.Are the events in compliance with NFPA 1126 (Standard Code for the Use of Pyrotechnics before a Proximate Audience)? Yes No
121.Is the facility sprinklered? Yes No
122.What other form of fire fighting equipment is available at the facility?
123.Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
124.Number of accessible (not locked) emergency exits at the facility:
125.What steps are taken to inform patrons of the locations of all emergency exits?
126.Maximum capacity of the facility:
127.Has the fire marshal approved the use of pyrotechnics at the facility? Yes No
If yes, as of what date:

Please provide the following with this application: