MOTOR SPORTS RACE TEAM INSURANCE QUESTIONNAIRE
§ NOTE: This questionnaire is to be submitted along with the following completed forms:
o ACORD Applicant Information application 125
o ACORD Commercial General Liability Section 126
o ACORD Applications for other requested coverages: Property; Garage; Crime; Inland Marine; Transportation; Excess Liability; Employment Related Practices.
GENERAL INFORMATION1. Name of Insured (Applicant):
2. What is the insured’s FEIN number?
3. What is the insured’s website address?
4. Number of years in business?
5. Effective Date of Insurance Coverage
PAST INSURANCE EXPERIENCE
6. Do you presently carry insurance of this type? Yes No
If yes, with which insurer?
7. Have coverages ever been canceled or non-renewed during the last five (5) years? Yes No
If yes, please explain:
8. Insurance Experience information for Past Five Years:
Carrier
Year
Premium / $ / $ / $ / $ / $
Total Insured Claims
(Paid & Reserve)
9. Description of any individual claim or reserve in excess of $10,000:
UNDERWRITING INFORMATION
10. Please describe the operation of each named insured and their relationship to the first named insured
(use separate sheet if necessary)
11. / Coverage Requested / Limit Requested
Primary General Liability / $ / Deductible: / $
Participant Legal Liability / $
Personal Injury / $
Product Liability / $
Damage to Premises Rented to You: / $
Products/Completed Operations Liability: / $
Self-insured retention / $
Racing Liability Coverage needed? Yes No
Excess Liability – Limit Required: $
Property/Crime Inland Marine/Off Track
Liquor Liability Directors & Officers
Auto Liability/Physical Damage
Accident Medical:
Limit Required: Excess Medical $ Deductible $ AD&D $
12. Describe your racing experience:
13. What racing series do you participate in?
How many entries do you field in each race?
Are drivers employees or independent contractors?
If independent contractors, please provide a copy of the driver agreement.
14. PLEASE PROVIDE A COPY OF YOUR ANTICIPATED RACING AND PRACTICE SCHEDULE. MAKE SURE THAT SCHEDULE INCLUDES DATES AND LOCATIONS FOR ALL RACES AND PRACTICES. (See Page 6)
15. Describe any other business activities the named insured is involved in:
16. Please list all properties that you own, rent, or occupy. For those garage locations that you own, rent, or occupy, please complete the garage information section below.
Property Location 1:
Address:
Street / City / State / Zip
Property Location 2:
Address:
Street / City / State / Zip
Property Location 3:
Address:
Street / City / State / Zip
GARAGE INFORMATION:
Garage Location 1:
a. Address:
Street / City / State / Zip
b. Type of Construction:
c. Age of the Facility:
d. Square Footage:
e. Describe Security at Storage Location:
f. Describe any Fire Protection:
g. Distance to nearest Fire Station:
h. Any Fuels Stored? Yes No
If yes, describe the type and quantity:
i. Do you own or lease the premises? Own Lease
j. Are premises currently covered under a commercial general liability policy? Yes No
If yes, name of carrier, coverage limits:
Garage Location 1:
a. Address:
Street / City / State / Zip
b. Type of Construction:
c. Age of the Facility:
d. Square Footage:
e. Describe Security at Storage Location:
f. Describe any Fire Protection:
g. Distance to nearest Fire Station:
h. Any Fuels Stored? Yes No
If yes, describe the type and quantity:
i. Do you own or lease the premises? Own Lease
j. Are premises currently covered under a commercial general liability policy? Yes No
If yes, name of carrier, coverage limits:
17. PLEASE ATTACH A LIST OF ALL OF YOUR CORPORATE SPONSORS (See Page 7)
18. Are you involved in any overseas activities? Yes No
If yes, please describe:
19. Do you manufacture or design any products (e.g. Vehicle Chassis)? Yes No
If yes, please describe:
20. Do you sell the products you design or manufacture? Yes No
If yes, please give the estimated annual receipts: / $
21. If your product is manufactured by any outside firm, please attach a copy of your contract with each firm.
22. Do you use any owned or non-owned aircraft? Yes No
If yes, please describe:
A. PROPERTY COVERAGE
(If Property coverage is desired, please complete the ACORD Property Application 140 and answer the questions in Section A.)
23. Are there any renovations or additions planned during the proposed policy period (including values)? Yes NoIf yes, please describe:
24. If painting or renovating work is being performed by a subcontractor, do you secure a Certificate of Insurance from the subcontractor that includes coverage for General Liability? Yes No
25. Are any flammables stored at this facility? Yes No
If yes, are all flammables contained and stored in UL and NFPA approved cabinets and/or containers? Yes No
26. Is any painting or fiberglass work performed? Yes No
If yes, do you have a UL approved paint booth? Yes No
If no, please describe:
27. Does air flow and filtration system meet OSHA and local requirements? Yes No
28. Does your maintenance staff perform welding? Yes No
Do you have a training program for welding? Yes No
29. Please describe your watchman, security, or regular ownership presence during non-operational period.
Are buildings equipped with alarms? Heat Smoke Intrusion
Are alarms tested and maintained regularly? Yes No
Are alarms connected to central station alarm? Yes No
30. Please describe your property stored at non-owned buildings:
B. AUTOMOBILE COVERAGE & TRANSPORTATION INFORMATION
31. Does the team own any vehicles? Yes NoIf yes, please provide a completed ACORD Auto Application including Auto Schedule.
32. Does the team allow the use of employees’ personal autos for company business? Yes No
If yes, number of people employed by the team:
33. Does the team rent vehicles? Yes No
If yes, is rental coverage purchased from the rental agency? Yes No
Estimated number of rental days:
General description of the exposure (employees run errands, etc., rental/lease, contracted transportation, hauling):
34. Are all drivers covered by workers’ compensation? Yes No
35. Is there a written policy with respect to the use of company vehicles? Yes No
36. Are employees allowed to use company vehicles for personal use? Yes No
37. Can family members drive company vehicles? Yes No
38. Explain the driver selection process (age review, independent MVR review, confirmation of primary insurance, proof of valid drivers license):
39. What does the team do if an individual is found to have three or more moving violations or a DUI or an OUI- type of violation?
40. Does the team have a driving safety/training program? Yes No
If yes, please provide a copy of the driving safety training program manual.
41. Where are the vehicles being stored?
42. Are there protections in place at the area where vehicles are stored? Yes No
If yes, please explain:
43. Is there a concentration of values or exposure (major exposure is within a certain time frame) with respect to this insured? Yes No
If yes, explain:
44. Travel to Canada or Mexico? Yes No
45. Description of any high valued vehicles (over $75k):
46. Does the association have a vehicle maintenance program? Yes No
47. What’s the majority radius of the auto fleet?
48. Does the team utilize the service of a charter bus company? Yes No
If yes, please provide a copy of the agreement.
49. Does the team require evidence of insurance from the charter bus company naming the team as an additional insured? Yes No
If yes, please provide a copy of the certificate of insurance.
50. Does the team own any aircraft? Yes No
If yes, please describe:
Please provide a copy of the policy providing coverage for the aircraft.
51. Does the team charter any aircraft? Yes No
If yes, please provide a copy of the airline charter agreement.
52. Does the team require evidence of insurance from the charter airline naming the team as an additional insured?
Yes No
If yes, please provide a copy of the certificate of insurance.
Name of Race Team:
RACING SCHEDULE ATTACHMENT
Date / Track Location / Event / Practice / ExhibitionName of Race Team
CORPORATE SPONSOR SCHEDULE
Sponsor Name / Sponsorship Involvement / Sponsorship Agreement (check one)Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
For any sponsorship relationship where there is a signed agreement, please include a copy of the agreement.
The following information is required to provide an insurance quote:
· The Motorsports Race Team Insurance Questionnaire or equivalent information in another format
· Race schedule for upcoming year (Page 5 of this Questionnaire or a separate attachment)
· Promotional schedule for upcoming year
· 5 years currently valued loss runs
If the following coverages are required, please complete ACORD applications:
· ACORD Applicant Information 125
· ACORD Property Section 140
· ACORD Business Auto Section 127
· ACORD Business Auto Section 127
(State Specific)
· ACORD Umbrella Section 131
I hereby represent and confirm that I have read all of the questions and answers contained herein and that, to the best of my knowledge, the information is true and correct.
I further acknowledge that I understand that this information is provided in conjunction with and in addition to the ACORD application(s) referenced above and that the information contained herein is subject to the same notices, disclaimers, warranties, and representations as on the referenced application(s).
Date Signature of Insured or Authorized Representative Title
Send completed form along with referenced ACORD application(s) to:
American Specialty Insurance & Risk Services, Inc.
7609 W. Jefferson Blvd.
Suite 100
Fort Wayne, IN 46804
Phone: (800) 245-2744
E-mail:
Form No. I/A AMSP.RACE.TEAM.QUEST. (10/14) Page 1 of 7 SP # 5998321
ÓAmerican Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved.