Motorsports Tracks Insurance Application

MOTORSPORTS TRACKS INSURANCE APPLICATION

BROKER INFORMATION

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

GENERAL INFORMATION

1.Named Insured:
2.Address:
Street / City / State / Zip

1. Proposed insured is a (check one): Corporation Partnership

Individual Other (specify):
4.Is the proposed insured a subsidiary of another company? Yes No
If yes, name of parent company:
5.Contact person:
Phone: / Fax:
6.How long has present management managed this facility?

Please provide copies of loss runs for the previous five (5) years including paid losses and outstanding reserves.

7.Have coverages ever been canceled or non-renewed during the last five (5) years? Yes No

If yes, please explain:

8.Please provide most audited financial statements.
9.Please provide breakdown for the following categories:
a.Gate Receipts / $
b.Concession Receipts / $
i.Food and drink / $
ii.Liquor / $
iii.Merchandise / $
c.Parking Receipts / $
10.Does the facility have a licensing agreement with any firm to provide products, souvenirs or apparel? Yes No
If yes, please provide a copy of the agreement. If the agreement provides for evidence of insurance, please provide a certificate of insurance for the licensor.
11. List all premises leased, rented, or occupied by Named Insured.
Address:
Street / City / State / Zip
Interest in Location: / Square Footage:
Address:
Street / City / State / Zip
Interest in Location: / Square Footage:
Address:
Street / City / State / Zip
Interest in Location: / Square Footage:
12. Do you rent out the facility to others? Yes No
If yes, is the facility listed as an additional insured under the tenant user’s policy? Yes No
Is there a system in place for obtaining certificates of insurance where applicable? Yes No
If yes, who reviews certificates on behalf of named insured?
What is the minimum limit of general liability coverage requested from each tenant user?

COVERAGES AND LIMITS APPLIED FOR

(Please provide a copy of expiring policy)

13. (Please provide a copy of expiring policy)
Commercial general liability
General aggregate
Participant bodily injury
Products and completed operations (aggregate)
Personal and advertising injury
Fire legal liability
Self-Insured retention:
Other:
Excess/Umbrella Liability – Limit Required: $
Property/Crime Auto Liability/Physical Damage
Liquor Liability Directors & Officers
Accident Medical
14.Additional Insureds and their business relationship to Named Insured:
Additional Insured / Relationship
15. Location of Tracks Same as Named Insured Other:
16. Track Type: Oval Road Course Drag Other
Track Length:
Track Surface: Asphalt Concrete Other
17. Is there a perimeter fence? Yes No
If yes, what type: / Height:
Number of Entrances: / PLEASE ILLUSTRATE ON TRACK DIAGRAM.
18.Does entrance have gate? Yes No
How is it secured?
Chain: Yes No
Locked: Yes No
Open: Yes No
19. Number of flag positions: / Protected: Yes No
20.Are guardrail ends protected from oncoming vehicles? Yes No
21.Are track barriers installed to protect race vehicles from unusual hazards (light poles, steep banks, etc.) Yes No
If no, please explain:

TRACK PROTECTION

A. Barrier Permanent Temporary
Concrete / Armco
Height
Width or No.
Support Posts
Distance Apart
Earth Backed
Guardrail Location (Mark on Diagram)
B. Wheel Fence
Chain Link / Woven Wire / Weld Wire
Height above track
Type of support posts
Distance apart
Anchored (Yes or No)
Wheel Fence Location (Mark on Diagram)
Cable: Yes No / Size: / Number of Strands: / Dimensions of wire:

PIT AREA (Mark location of pit area on diagram)

22.Is Pit Area access and all exits visible from Officials stand? Yes No
23. Is each person entering the pit area required to sign an approved Release and Waiver? Yes No
If no, please explain:
24.Will there be adequate warnings and notices ("No Smoking", "Authorized Personnel Only", "No Admittance")
posted in the pit area forbidding unauthorized entry? Yes No
25.Describe the fire suppression measures for the pit area:
26.Number and type of fire extinguishers:
A. BARRIER Yes No
Concrete / Armco
Height
Width or No.
Support Posts
Distance Apart
Earth Backed
Is there a Pit Area Viewing Area? Yes No
If yes, is it separated from regular pits by crowd control fence? Yes No
Does area contain separate rest rooms and concessions? Yes No
Does area have grandstands? Yes No
If yes, are there railings on these grandstands? Yes No
Is there guardrail between the pit area and track with crowd control fence to restrict spectators behind guard rail?
Yes No
B. PIT VIEWING AREA CROWD CONTROL FENCE Yes No
(Mark location on Diagram)
Chain Link / Woven Wire / Snow Fence
Height
Support Posts (Yes or No)
Distance Apart
Distance to Guardrail
Describe fueling arrangements and procedure.
Are there permanent fuel tanks: Yes No
If yes, are they: above ground buried
Are there overhead wires: Yes No
Minimum height:

SPECTATOR CONVENIENCES

A. Grand Stands Yes No
Minimum Distance between spectator viewing area and track: / feet
Mark location and assign reference number to each section on diagram. Code abbreviations:
W - WoodM - MetalC - Concrete
Number and Type of Seats (Grandstand)
Seats (W/M/C)
Frame (W/M/C)
Footing Type
Hand Rails (Yes or No)
Seats (Yes or No)
Number of Rows High
Is grandstand: Frontload Backload
Is area under grandstand used for open storage? Yes No
Estimated stored value: / $
B. Parking Area
On Premises Across RoadDistance from Spectator Viewing Area:
Paved Dirt Grass Level Sloped
Free of obstacles? Yes No
Is Parking Area Security Patrolled? Yes No
Does parking area have sufficient lighting? Yes No
If no to any question, explain:

SCHEDULE OR CALENDAR OF EVENTS

Please attach a copy of the schedule or calendar of events to this application. Please indicate what types of events are scheduled.
A.CAMPGROUNDS
(Please complete this section if you need a quote for Campground Coverage. If you do not need a quote for Campground coverage, please skip this section and continue to the next section.)
27.Please provide total acreage for the campground:
28.What are the anticipated total annual admissions for the campground?
Campers: / Trailers: / Other: / Total:
29.Do you make a separate charge for camping? Yes No
30.Is camping limited to event dates only? Yes No
31.Does the campground provide RV hook-ups? Yes No
32.Does the campground offer bathrooms, showers, etc? Yes No
33.Is there someone on-site 24 hours during camping times? Yes No
34.Is there a first aid station at the campground? Yes No
Is it staffed with licensed medical personnel? Yes No
Is the nearest hospital or medical clinic 10 minutes from the campground? Yes No
35.Is the fire department within 5 miles or five minutes of the campground? Yes No
Is there an employee fire brigade for the campground? Yes No
36.Is the campground properly licensed? Yes No
Does it meet all applicable state and local codes? Yes No

SECURITY, EMERGENCY, MEDICAL, AND SAFETY PLAN

37.a.Number and type of security personnel:
Professional Services:
Uniformed Officers – Off-Duty: On-Duty:
Employees: / Armed: Yes No
b. How many staffed ambulances are on-site during event?
c. Name of nearest hospital: / Phone Number:
d. Distance to hospital: / EmergencyCenter: / Fire Station:
e. Is there a separate, staffed facility for spectator first aid treatment? Yes No
f. Is there any open water on premises? Yes No
If yes, how large? / (show on diagram)
Depth: / Distance from any spectator viewing/parking areas:
Is it fenced off? Yes No
g. Number, type, and size of fire extinguishers on-site during events?
h. Are all known township, city, county, state, and/or federal public building, seating, concessions, and sanitation codes being complied with? Yes No
If no, please explain:
i. Are security personnel contracted or employed? Contracted Employed
38.a.Do you permit alcoholic beverages on the premises? Yes No
b.Are alcoholic beverages sold?* Yes No
*If yes, please complete the Liquor Liability Section
c. Are signs posted in high traffic areas or announcements made indicating assumption of risk?
Yes No
d. Are all areas available to spectators and participants inspected before each event for slip and fall hazards? Yes No
e.Are concessions owned/operated by Insured? Yes No
Leased? Yes No
If operated by others, provide a copy of agreement between track and concessionaire with this application.
39.Person responsible for general operation of facility activities:
CONTRACTUAL
40.Provide copies of any lease agreements other contractual agreements.
41.Where subcontractors are utilized, is the proposed named insured listed as an additional insured under the subcontractor's policy? Yes No
Is there a system in place for obtaining certificates of insurance where applicable? Yes No
If yes, who reviews certificates on behalf of named insured?
What is the minimum limit of general liability coverage requested from each subcontractor?
PARTICIPANT LIABILITY:
42.Is Statutory Workers' Compensation Insurance carried? Yes No
If not, are you a qualified self-insurer? Yes No
43.Has there been any participant bodily injury losses for the facility over the past five years? Yes No
If yes, please provide amount and explanation of each.
Amount / Explanation
$
$
ADVERTISING EXPOSURE
44.Annual advertising expenditure: / $
List all media used:
Is an advertising agency used? Yes No
If yes, name and address of agency:

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.)

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

C.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.)

71.Does applicant have a full-time Personnel Department? Yes No
72.Number of employees under Employee Benefit Program administered in the U.S. or Canada:
73.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
74.List below any other types of benefit programs the applicant wants the company to consider for inclusion under this insurance:
Type of Benefit Program
75.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
76.Is a benefit brochure or written explanation of the Employee Benefits Program given to each employee? Yes No
77.Are all benefits available to all employees? Yes No
If no, list all exceptions:
78.Who advises the employees of their benefits?
Personnel Manager / Department Manager / Immediate Supervisor / Other (Please describe):
79.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
80.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:
81.Has any occurrence taken place in the past that is likely to give rise to a claim? Yes No
If yes, please give details:
82.Number of branches, other business locations:
83.How are employees in branches and other locations advised of benefits?
84.What is the first date any previous Employee Benefits Liability coverage was carried?

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.)

85. Limit of liability requested: $1,000,000 Other:
86. Description of Events:
87. Location of Events:
Street / City / State / Zip
88. Dates of Events:
89.Who is the Authority having jurisdiction over the use of pyrotechnics at your facility?
Local Fire Department State Fire Marshal Other (please list):
90.What permit process must be followed prior to use of pyrotechnics at your facility:
91.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.
92.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. 93.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
94. Are events with pyrotechnics held: Indoors Outdoors
95.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)
96.Are the events in compliance with NFPA 1123 or 1126 (Code for Fireworks Display)? Yes No
97.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:
98.Will there be firefighting equipment on site during the event? Yes No
99.If no firefighting equipment on site, give distance to nearest fire station:
100.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)
101.Are the events in compliance with NFPA 1126 (Standard Code for the Use of Pyrotechnics before a Proximate Audience)? Yes No
102.Is the facility sprinklered? Yes No
103.What other form of fire fighting equipment is available at the facility?
104.Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
105.Number of accessible (not locked) emergency exits at the facility:
106.What steps are taken to inform patrons of the locations of all emergency exits?
107.Maximum capacity of the facility:
108.Has the fire marshal approved the use of pyrotechnics at the facility? Yes No
If yes, as of what date:

E.SECURITY COVERAGE

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

PART I
109.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:
110.Do any security personnel carry a firearm as part of their equipment while on duty? Yes No
If yes, number of armed security personnel:
111.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.
112. If applicable, please provide the estimated payroll for employed security persons.
113.Total maximum hours per day permitted at this and all other places of employment:
Total maximum hours per week?
114.What are the staffing guidelines per number of patrons?
115.Are the guidelines determined by: Ordinance, or Statute?
Industry standard? Yes No
Other (please describe):
PART II:
116.Is there a pre-employment screening procedure? Yes No
If yes, please describe:
117.Does the procedure include contacting previous employers over the previous five years? Yes No
118.Do you contact at least three personal references? Yes No
119.Is a psychological screening profile used? Yes No
If "yes," what type:
120.Is a criminal background check made? Yes No
If "yes," what agency is used for the criminal background check?
121.Is completion of a minimum 20 hours initial training program required before deployment? Yes No
122.Who conducts the training and what are the trainers qualifications:
123.Is a minimum of 10 hours on-site training required? Yes No
124.Is a minimum of 4 hours of annual refresher or continuing education training planned and conducted for each
security employee? Yes No
125.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:
126.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.
127.Are the security personnel identified by other than a uniform? Yes No
If "yes," please describe the identification and include an example or photograph.
128.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
129.Describe capabilities of each guard for constant communications with each other, the supervisor, and park
management:
130.Are dogs used in your security operations? Yes No
If yes, please provide the type of dog(s), number, and describe duties.
PART IV:
131.Date the contracting company began business:
132.Is there a written agreement with contracting company? Yes No
If "yes," Please enclose a complete copy of the written agreement
133.Name of contracting company's liability insurance carrier:
134.Is the park an additional insured on that policy? Yes No
If "yes," please enclose a complete copy of the policy.
135.Is there an established working relationship with local law enforcement? Yes No
If "yes," please describe:
136.Please attach a copy of the contracting company's employment procedures.
137.No. of contracted security personnel: / No. of security supervisors:
138.Are there any suits or legal actions pending against the company? Yes No
If yes, please explain in detail:
139.Is there a procedure to immediately report all incidents to park? Yes No
If yes, please describe:
PART V:
140.Does the supervisor make personal contact with each security person at least once during each shift?
Yes No
If "yes," please describe:
141.Please explain all "no" answers.

F.TRANSPORTATION