Amateur Sports Event(S)

AMATEUR SPORTS EVENT(S)

INSURANCE APPLICATION

BROKER INFORMATION

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

GENERAL INFORMATION

1.Name of Insured (Applicant):
2.Address:
Street / City / State / Zip
3.Phone: / Fax:
4.Form of Business: Corporation Joint Venture Partnership
LLC Other (please describe):
5.Is the insured considered: For Profit Not-for-profit / Federal ID #
6.Date of Formation: / Chartered or Incorporated in What State?
7.Proposed Effective Date: / Website:

EVENT INFORMATION

8.Name of Event: / Type of Event:
9.Venue Address
Street / City / State / Zip
10.Dates of Event: / Set-up/tear down dates:
11.Is this an annual event? Yes No
12.Event Manager: / Experience:
Event Risk Manager:
13.Are overnight accommodations or camping facilities provided for the event attendees or contracted for by the event organizer? Yes No
If yes, please provide a copy of the contract.
14.No. of participants over 18 years: / No. of participants 18 years and under:
No. of coaches/managers: / No. of officials/umpires:
No. of volunteers: / No. of employees:
Average daily spectator attendance:
15.Will the event have vendors or exhibitors? Yes No
If yes, do you require that each vendor/exhibitor carries insurance and lists you as an additional insured? Yes No
If no, do you require a vendor hold harmless/indemnification agreement (in your favor) be signed?
Yes No

INSURANCE/UNDERWRITING INFORMATION

16.Responsibilities:
Please specify who has responsibility for the following event day operations:
Insured / Facility / Subcontractor/Other (please list)
Facility Maintenance
Maintenance of event area
Concessions - Non Alcohol
Concessions – Alcohol*
First Aid
Parking
Security*
Premises Defects
Transportation*
Fireworks*
Parade*
*If the insured handles this function, a separate application is required.
Please provide copies of all facility/venue agreements and/or subcontractor agreements.
17.Describe security protection:
18.Describe procedures for patron eviction and/or arrests:
19.Describe the precautions taken to prevent spectators from entering restricted areas. If an outdoor event, please describe fencing and other means to prohibit entry by non-ticket holders:
20.Type of medical facility/ambulance provided?
21.Grandstand:TypeNo. Age in Years
Permanent
Temporary
22.If temporary bleachers used, do you require a Certificate of Insurance naming you as an additional insured from the owner of the bleachers? Yes No
If yes, please attach.
23.What percentage of attendance will be festival seating; i.e., non-reserved?
24.How long before scheduled performance time will you allow entry of spectators?
25.Are ushers used? Yes No
26.Describe number and types of gates and turnstiles:
27.What type of concessions are sold?
28.Will concessionaires provide you with Certificates on Insurance evidencing products liability with your organization as Additional Insured? Yes No
29.Who is responsible for pre-event inspection of the event premises?
30.Will any other underlying coverage be provided for this event? Yes No
If yes, please describe:
31.If your organization is a member of a trade group or sanctioning body which hold insurance and/or risk management seminars and/or meetings, indicate name of association:
32.Is this a sanctioned event? Yes No
If yes, name sanctioning organization:
33.Will you have remote parking? Yes No
34.What arrangements have been made for shuttle service?
35.How is this event being advertised?
36.Is facility in compliance with city, state, and township building, safety, and fire codes? Yes No
(NOTE: Non-compliance with codes will invalidate insurance)
37. / 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: / $ / $
38.Please describe participant personal accident coverage provided for your association:
Carrier: / Primary Excess
Accident Limits: / Accidental Death & Dismemberment limits: $
Catastrophic Limits:
39.Are athletic members covered by Workers Compensation? Yes No
If yes, please explain:
40.Is there any form of athlete compensation or prize money awarded for participation? Yes No
If yes, please explain:
41.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/volunteers):
B.When are the waivers signed?
C.How long are the waivers kept? (e.g. statutory):
D.Where are the waivers stored? (e.g. warehouse):
42.Please list all Additional Insureds and their relationship to the Named Insured (use additional sheet of paper
if necessary):
Additional Insureds / Relationship to Named Insured
43. Estimated gross receipts:
Breakdown of Receipts:
Rentals: / Media contracts:
Admissions: / Advertising:
Membership dues: / Parking receipts:
Concessions/Food: / Beer and liquor receipts:
Novelty and other merchandise: / Other (please list):
Comments:

PAST INSURANCE EXPERIENCE

44.Do you presently carry insurance of this type? Yes No
If yes, with which insurer?
45.Has any insurer ever canceled or refused coverage? Yes No
If yes, explain:
46.Insurance experience information for Past Five Years First year for the event
Carrier / $ / $ / $ / $ / $
Year / $ / $ / $ / $ / $
Premium / $ / $ / $ / $ / $
Total Insured Claims (Paid & Reserved) / $ / $ / $ / $ / $
47.Description of any individual claim or reserve in excess $10,000:

A.ABUSE AND MOLESTATION

(This section must be completed.)

48.Does the insured have custodial responsibility for minors? Yes No
If yes, is abuse coverage desired? Yes No
49. 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?
50.(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
51.(a)Do you verify employment-related references for employees? Yes No
(b)Do you verify employment-related references for volunteers? Yes No
52.(a)Do you conduct a personal interview for employees? Yes No
(b)Do you conduct a personal interview for volunteers? Yes No
53.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.
54.Do you have an Abuse / Molestation Policy with regard to sexual abuse? Yes No
If yes, please indicate how it is transmitted to your employees/volunteers.
55.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.
56.Describe how your organization supervises employees and volunteers having custody of children.
57.Describe specific policy regarding any overnight travel.
58.(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?
59.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?
60.Please indicate age range of minors in your care or under the supervision of your employees or volunteers at any time.
61.Please describe your current and/or planned operations that involve the custodial care of minors.

B.SECURITY COVERAGE – (Complete only if security is the responsibility of by the insured)

PART I
62.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:
63.Do any security personnel carry a firearm as part of their equipment while on duty? Yes No
If yes, number of armed security personnel:
64.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 fromthe 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.
65. If applicable, please provide the estimated payroll for employed security persons.
66.Total maximum hours per day permitted at this and all other places of employment:
Total maximum hours per week?
67.What are the staffing guidelines per number of patrons?
68.Are the guidelines determined by: Ordinance, or Statute?
Industry standard? Yes No
Other (please describe):
PART II:
69.Is there a pre-employment screening procedure? Yes No
If yes, please describe:
70.Does the procedure include contacting previous employers over the previous five years? Yes No
71.Do you contact at least three personal references? Yes No
72.Is a psychological screening profile used? Yes No
If "yes," what type:
73.Is a criminal background check made? Yes No
If "yes," what agency is used for the criminal background check?
74.Is completion of a minimum 20 hours initial training program required before deployment? Yes No
75.Who conducts the training and what are the trainers qualifications:
76.Is a minimum of 10 hours on-site training required? Yes No
77.Is a minimum of 4 hours of annual refresher or continuing education training planned and conducted for each
security employee? Yes No
78.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:
79.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.
80.Are the security personnel identified by other than a uniform? Yes No
If "yes," please describe the identification and include an example or photograph.
81.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
82.Describe capabilities of each guard for constant communications with each other, the supervisor, and park
management:
83.Are dogs used in your security operations? Yes No
If yes, please provide the type of dog(s), number, and describe duties.
PART IV:
84.Date the contracting company began business:
85.Is there a written agreement with contracting company? Yes No
If "yes," Please enclose a complete copy of the written agreement
86.Name of contracting company's liability insurance carrier:
87.Is the park an additional insured on that policy? Yes No
If "yes," please enclose a complete copy of the policy.
88.Is there an established working relationship with local law enforcement? Yes No
If "yes," please describe:
89.Please attach a copy of the contracting company's employment procedures.
90.No. of contracted security personnel: / No. of security supervisors:
91.Are there any suits or legal actions pending against the company? Yes No
If yes, please explain in detail:
92.Is there a procedure to immediately report all incidents to park? Yes No
If yes, please describe:
PART V:
93.Does the supervisor make personal contact with each security person at least once during each shift?
Yes No
If "yes," please describe:
94.Please explain all "no" answers.

C.LIQUOR LIABILITY APPLICATION

(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.)

95. Named Insured:
Address:
Street / City / State / Zip
Contact Person:
Phone: / Fax:
96.Name on liquor license:
97.Liquor license number: / Class of license:
98. 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:
99.Has applicant's liquor license ever been revoked or suspended? Yes No
If yes, please explain:
100.Has applicant incurred claims for liquor liability during the last 3 years? Yes No
If yes, please explain:
101.Has any insurer cancelled or non-renewed coverage during the last 3 years? Yes No
If yes, please explain:
102.Has applicant ever been fined by alcoholic beverage control or other governmental regulator? Yes No
If yes, please explain:
103.Type of beverages sold:
104.Annual Gross Sales:
Liquor Sales $
Food Sales$
Other$
105.Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If yes, what type?
106.Do you exercise the right of search and seizure of contraband items? Yes No
If yes, how do you notify the public of this?
107.Do you maintain security personnel at entry check points? Yes No
If yes, what type?
108.Are the alcohol sales and consumption: Contained within one fixed site, or Are booths/stands located throughout the event site?
109.Number of servers used?
Professional? Yes No Explain:
Volunteer? Yes No Explain:
110.Do the servers receive any type of alcohol awareness training? Yes No
If yes, please explain:
(attach training manuals used)
111.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?
112.Explain how ID's are checked:
113.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?
114.Are rules and regulations clearly displayed for patrons viewing? Yes No
Describe:
115.In what size of container is the alcoholic beverage served? Cup Oz. Pitcher
Other
116.Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No
Explain:
117. Is there entertainment provided? Yes No
Live music? Yes No
Disc Jockey? Yes No
Type of music:
118.Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No
Explain:
119.Is there any type of designated driver program? Yes No
Explain:
120.Is there any other underlying liquor liability coverage being provided? Yes No
Explain:
121.Will there be additional limits of liquor liability purchased? Yes No
If yes, what is the additional limit?

D.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.)

122.Limit of liability requested: $1,000,000 Other:
123.Description of Events:
124.Location of Events:
Street / City / State / Zip
125.Dates of Events:
126.Who is the Authority having jurisdiction over the use of pyrotechnics at your facility?
Local Fire Department State Fire Marshal Other (please list):
127.What permit process must be followed prior to use of pyrotechnics at your facility:
128.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.
129.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)
87.130.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
131.Are events with pyrotechnics held: Indoors Outdoors
132.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)
133.Are the events in compliance with NFPA 1123 or 1126 (Code for Fireworks Display)? Yes No
134.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:
135.Will there be firefighting equipment on site during the event? Yes No
136.If no firefighting equipment on site, give distance to nearest fire station:
137.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)
138.Are the events in compliance with NFPA 1126 (Standard Code for the Use of Pyrotechnics before a Proximate Audience)? Yes No
139.Is the facility sprinklered? Yes No
140.What other form of fire fighting equipment is available at the facility?
141.Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
142.Number of accessible (not locked) emergency exits at the facility:
143.What steps are taken to inform patrons of the locations of all emergency exits?
144.Maximum capacity of the facility:
145.Has the fire marshal approved the use of pyrotechnics at the facility? Yes No
If yes, as of what date:

E.NON-OWNED AND HIRED AUTO LIABILITY