Amateursportscollege Athletic Conferences

AMATEURSPORTSCOLLEGE ATHLETIC CONFERENCES

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 (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 / Federal ID #:
6.Date of Formation: / 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:

INSURANCE INFORMATION

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?
*PLEASE ENCLOSE A COPY OF CURRENT OR MOST RECENT POLICY OR CERTIFICATE OF INSURANCE. *
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:

*PLEASE PROVIDE A COPY OF ALL RULE BOOKS AND ASSOCIATION MANUALS.*
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 spectators 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
(You must complete this section.)
39.Does the insured have custodial responsibility for minors? Yes No
If yes, is abuse coverage desired? Yes No
40. Does your staff (paid and volunteer) employment application include questions about whether the individual has ever been convicted of any crime, including sex-related or child abuse related offenses? Yes No
41. Does your state permit you to do criminal background investigations? Yes No
If yes, do you routinely request and receive such background investigations? Yes No
42.Do you verify employment related references? Yes No
43. Do you conduct a personal interview? Yes No
44. Do you have written procedures for dealing with sexual abuse? Yes No
If yes, please attach a copy.
45. Do you have a plan of supervision that monitors staff in day-to-day relationships with students, both on and off premises? Yes No
46. Has your organization ever had an incident which resulted in an allegation of sexual abuse Yes No
If yes, please describe:
Was a claim made against the organization? Yes No
Was the case settled? Yes No
Was the case taken to trial? Yes No
How much money was paid as damages to the victim?
B.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.)
47.Does applicant have a full-time Personnel Department? Yes No
48.Number of employees under Employee Benefit Program administered in the U.S. or Canada:
49.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
50.List below any other types of benefit programs the applicant wants the company to consider for inclusion under this insurance:
Type of Benefit Program
51.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
52.Is a benefit brochure or written explanation of the Employee Benefits Program given to each employee? Yes No
53.Are all benefits available to all employees? Yes No
If no, list all exceptions:
54.Who advises the employees of their benefits?
Personnel Manager / Department Manager / Immediate Supervisor / Other (Please describe):
55.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
56. 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:
57.Has any occurrence taken place in the past that is likely to give rise to a claim? Yes No
If yes, please give details:
58.Number of branches, other business locations:
59.How are employees in branches and other locations advised of benefits?
60.What is the first date any previous Employee Benefits Liability coverage was carried?

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.)

61. Limit of liability requested: $1,000,000 Other:
62. Description of Events:
63. Location of Events:
Street / City / State / Zip
64. Dates of Events:
65.Who is the Authority having jurisdiction over the use of pyrotechnics at your facility?
Local Fire Department State Fire Marshal Other (please list):
66.What permit process must be followed prior to use of pyrotechnics at your facility:
67.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.
68.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. 69.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
70. Are events with pyrotechnics held: Indoors Outdoors
71.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)
72.Are the events in compliance with NFPA 1123 or 1126 (Code for Fireworks Display)? Yes No
73.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:
74.Will there be firefighting equipment on site during the event? Yes No
75.If no firefighting equipment on site, give distance to nearest fire station:
76.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)
77.Are the events in compliance with NFPA 1126 (Standard Code for the Use of Pyrotechnics before a Proximate Audience)? Yes No
78.Is the facility sprinklered? Yes No
79.What other form of fire fighting equipment is available at the facility?
80.Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
81.Number of accessible (not locked) emergency exits at the facility:
82.What steps are taken to inform patrons of the locations of all emergency exits?
83.Maximum capacity of the facility:
84.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.)

85.Does the Insured have any owned automobiles? Yes No
If yes, who is the insurer?
Limits of coverage: / Effective date of coverage:
86. 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
87.Do you have a driver screening program for those employees who use their own personal vehicles for your business purposes? Yes No
88.Do you obtain Motor Vehicle Reports? Yes No
If yes, how often? Annually Every other year Other
89.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?
90. Please provide the approximate cost of hire for all hired or leased autos during the
course of the policy period: $
91. Do you have a driver training program for employees who use owned vehicles or their own personal vehicles?
Yes No
92.Limits of coverage required: $100,000 $300,000 $500,000 $1,000,000 Other
93.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

Please provide the following with this application:

• Five years of currently valued company loss runs.
• Most current audited financials.
• Copy of expiring policy or specific manuscript endorsements that the insured would like to submit for consideration.
• List of all locations to be insured, including addresses and descriptions of each location.
• List of all insureds to be included along with a description of each.
• Copy of the promulgated rules and/or the website link where rules can be reviewed, if applicable.
• Copy of all rule books and association manuals
• Copies of subcontractor (bleachers, concessionaires, security, pyrotechnicians) agreements or agreements between the insured and any additional insured.
• Copies of certificates of insurance from each subcontractor naming the insured as an additional insured.
• Copy of waiver and release and athlete registration form.
• Copy of your written set of procedures for screening employees and volunteers.
• Copy of your Abuse / Molestation Policy with regard to sexual abuse including written procedures for dealing with allegations of sexual abuse.

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

• ACORD Applicant Information 125
• ACORD Property Section 140
• ACORD Inland Marine Section 146
• ACORD Business Auto Section 127
• ACORD Business Auto Section 127

(State Specific)

• ACORD Umbrella Section 131

Generic Fraud Warning Language:

Any person, who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

NOTICE TO RESIDENTS OF:

Alabama, Alaska, Arizona, Arkansas, California, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Washington, West Virginia, Wisconsin, Wyoming

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.

Maine, Tennessee, Virginia

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.

Colorado

It is unlawful to knowingly provide false, incomplete or misleading facts or information 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

District of Columbia

WARNING: 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.

Kentucky

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

Maryland

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.

New Jersey

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

New York

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.