AIG INSURANCE SPORTS GENERAL LIABILITY APPLICATION

AIG INSURANCE
SPORTS GENERAL LIABILITY APPLICATION
Application Instructions
A. Please type or complete the application in ink.
B. If additional space is needed, please use your firm’s letterhead.
A. Applicant Information
1. Applicant Company Name: _____________________________________________________
DBA: _________________________________________________________________________
2. Additional Named Insureds:
_____________________________________________________________
_____________________________________________________________
3. Mailing Address: _____________________________________________________________
4.
Physical Address 1:__________________________________
Physical Address 2: _____________________________________________________________
5.
C i t y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ State:_______________ Zip Code: ___________
6.
Contact Name: ______________________ Phone:______________________
7.
FEIN Nu mber:________________________________________
8.
Type of Business (circle one):
Individual
Corporation
Joint Venture
Partnership
Organization
Limited Liability Corp
University
Other
If Other, please describe: ______________________________________
9.
Effective Date: ______________________________
10. Expiration Date: _______________________________
11. Website: _____________________________
12. Is this operation for Profit? _____________________
13. Type of Group (circle one):
Association Club
Camp-Day Camp-Overnight Clinics Facility (Cheer/ Dance /
Gymnastics / Martial Arts) Facility (Batting Cage)* Facility (Yoga)
Facility (Other)* Facility
Health Club / Fitness* Higher Education Intramurals / Academic Clubs* League
National
Governing Body
Not-For-Profit
Semi-Pro / Professional Team (contact
underwriter)*
Special Event
State Athletic Association
Team
Tournament
Other
If Other, Describe ____________________________________________
*INDICATES SUPPLEMENTAL APPLICATION MUST BE EMAILED TO
UNDERWRITER
B. Sports Coverage
1. How many years has the organization operated?
If less than 3, does the applicant have prior experience? Yes/No
2. BATTINGCAGEFACILITYGOTO#3
Age
Sport
Group*: Played:
First
Practice
Date:
Sport
End
Date:
Total
Managers
Coaches, Volunteers:
Total
Players:
(mm/dd/yyyy)
Under 18
19 and over
3. Do you have trampolines Over 46”? YES/NO/N/A
4. Will activities include any of the following: Hang Gliding, Parasailing, Parachuting, Tobagganing, Luge,
Skateboarding, Trampolines over 46” in diameter, Bungee Jumping, Hot Air Balloons, Mechanical Bulls,
Saddle Animals, Velcro Jumps, Paintball, Race Track Risks, Boating, Motorsports, Rodeo, Mechanical
Rides, Inflatables, Overnight Clinic/Camps, Ski Jumping, Freestyle Skiing, Snowmobiling, Cheerleading
Pyramids over 2 ½ persons high and Cheerleading activities using trampolines and springboards,
Saddle Animal Rides, Petting Zoos, Racing and Speed Contests involving Autos, Racing and Speed
Contests involving Watercraft, Racing and Speed Contests involving Aircraft, Parades – Riding on Floats
or Motorized Devices, Pep Rallies, Tug of War, Licensed Daycare / Preschool Operations, Open Water
Activities, Repetitive Type Injuries to Horses / Ponies, Parkour Activities ? YES/NO
5. If applicable, will the standard safety gear for the sport be used? YES/NO/N/A
6. Does the organization require Waiver/Release forms from all participants or guardians, if appropriate?
YES/NO/N/A
7. If not, will your institute a program for Waiver/Release forms? YES/NO/N/A
(IF BATTING CAGE FACILITY, YOGA FACILITY, HEALTH & FITNESS FACILITY OR STATE
ATHLETIC ASSOCIATION, PLEASE SKIP THIS QUESTION AND GO TO #9)
8. Will accident and health coverage be in place for all participants? YES/NO
9. Are Cheerleading pyramids ever more than 2 persons high or are spring boards or trampolines ever
used? YES/NO/N/A
10.
Does the organization use or sell any type of Martial Arts/Tactical defense related weapon?
YES/NO
11.Does the organization have and enforce written standards regarding Sexual Abuse and Molestation?
YES/NO
12. Does the organization routinely request and receive criminal background investigations on all
employees, volunteers and independent contractors? YES/NO
13. Does the policyholder conduct camps for non-league/member participants? YES/NO
IF FACILITY, PLEASE ANSWER THE FOLLOWING QUESTIONS:
14. Do you have birthday parties? YES / NO
Number of Birthday Parties:
15. Do you own any inflatables? YES / NO
(CIRCLE TYPES)
Bouncer Type
Castles
Combo
Funland
Obstacle Course
Slides
Tents
Tunnels
Water Games
Other
16. Does the insured rent out the inflatables to others? Yes / No
17. Do you have overnight lock-ins or sleeping parties? YES/NO
If Yes, How many per year? __________________________________
18. Do you have a retail store on Premise?
Retail Store Receipts:
19. Does the applicant have a Day Care License? YES / NO
20. Is there separate insurance for the Day Care Operations?
21. Total receipts from membership dues:
22. If Health/Fitness Club, Are all trainers certified? YES / NO / N/A
23. Is there a restaurant and / or Liquor Bar in facility?
24. Total restaurant/liquor bar receipts:
25. Please check additional exposures below:
Booster Club
Soft Play
Climbing Wall (10 Ft high and under with pad)
Climbing Wall (10 Ft to 20 Ft high with helmet and harness)
Climbing Wall (over 20 Ft high with helmet and harness)
Height of Wall:
Proper supervision and controls in place? Yes/No
Are helmets and harnesses used on those walls over 10 feet? Yes/No
Swimming Pool:
Fenced? Yes/No
Rules Posted? Yes/No
Lifeguards on duty when in use? Yes/No
Diving Boards/Slides? Yes/No
Are all instructors certified? Yes/No
Zip Line (6 Ft high or under)
Zip Line (Over 6 Ft)
26. Is any sports equipment sold or rented? YES/NO
27. Are any nutritional supplements sold or distributed? YES/NO
28. If Yes, under applicant’s label? YES / NO
C. Policy Limits
1. Occurrence Limit: ________________________________
2. General Aggregate Limit: ___________________________
3. Personal & Advertising Limit: _______________________
4. Products – Completed Operations Aggregate: _________
Deductible (CIRCLE ONE): NONE; $250; $500; $1,000; $2,500; $5,000; $10,000;
OTHER
D. Coverages and Endorsements
1. D a m a g e T o Pr e mi s e s R e n te d T o Y o u : _ _ _ _ _ _ _ _ _ _ _
2. SML Limits: ___________________
3. Add Additional Insured(s)Other:Name _______________________
4. Add Additional Insured(s) - Managers or Lessors: Name: _________
___________________________________________________
5. Add Additional Insured(s) Designated Person or Organization: Name: _____
6. Add Additional Insured(s) State or Political Subdivision Permits:
Name:
__________________________________________
E. Camp Info (IF BATTING CAGE FACILITY MUST COMPLETE)
1 .
Age
Sport
Group*: Played:
C a m p
G R I D
Start
End
Staff and Total
# of # of
Date:
Date: Volunteers: Campers: Days: Events:
Under 18
19 and over
2. Is this the director’s first camp? YES/NO
If Yes, Describe experience?
3. Are there any other activities outside of the sports listed such as arts/crafts, field trips,
inflatables, etc.?
4. Number of Pitching Machines:
5. Do you have any other amusement devices and / or activities such as but not limited to inflatables,
go-carts, arcade, etc?
If Yes, explain.
6. Do you have Baseball field(s)?
If Yes, How Many?
7. Any safety equipment modification made by you?
If Yes, explain.
F. Operations
1. If the organization owns a venue, do they allow other organizations to use their facility? YES/NO/N/A
2. Does the organization have a Code of Conduct, Written Regulations and/or By-Laws? YES/NO
3. Is every league in this body required to provide liability insurance? YES/NO
4. How are league participants transported to events? ___________________________________
5. If buses are used, does the bus company provide a certificate of insurance? YES/NO/N/A
6. Who is responsible for maintaining the field/facilities?
G. Concussion Protocol:
1. Does your organization have a written concussion policy that is in compliance with
current state legislation? YES NO
2. Do you distribute the written policy to coaches, parents and players and require
parents acknowledgement that they have received and reviewed? YES NO
3. Does your concussion policy require a medical doctor’s release prior to the child
returning to play? YES NO
4. Does your concussion policy mandate that all coaches participate in concussion
training at least once every two years? YES NO
5. Does your organization utilize base line testing? YES NO
H. Claims History
1. Has the organization had any G/L and/or Sexual Abuse and/or Molestation claims and/ or incidents in
the last 3 years? YES/NO
If yes, total amount incurred?__________________________________________________________
I. SML Coverage (IF APPLICABLE)
1. Does the organization have and enforce written standards regarding Sexual Abuse and
ANSWER SHOULD CARRY OVER
Molestation?
2. Does the organization routinely request and receive criminal background investigations on all prospective
employees, volunteers and independent contractors? ANSWER SHOULD CARRY OVER
3. Does the employment application for your paid staff and volunteers include questions about whether the
individual has ever been convicted for any crime, including sex- related or child-abuse related offenses?
YES/NO
4. How do you verify employment and/or volunteer related references?
IN Person
/
By Telephone
Do Not Verify
5. Do you discuss child/sexual abuse including how to recognize the signs, and what to do if a staff personnel
child and/or volunteer reports someone molested him/her at your staff orientation? YES/NO
6. Do you document it? YES/NO/N/A
7. Do you have a plan of supervision that monitors staff including volunteers in day-to-day relationship with the
children? YES/NO
8. Do you have a crisis management plan for dealing with staff personnel, including volunteers, victim, parents,
authorities and media if you have an incident of abuse? YES/NO
J. Policy History
1. Current Insurance Carrier: ___________________________________________
2. Is there prior insurance coverage? YES/NO
3. Has insurance coverage been denied, cancelled or non-renewed during the last 3 years? YES/NO
4. If Yes, please explain: If No, enter N/A : ____________________________
5. Who will the A&H Medical coverage be placed with? _______________________
6. What is the deductible amount on the A&H Medical? _______________________
IMPORTANT NOTICE
IN GRANTING COVERAGE TO ANY OF THE INSUREDS, THE INSURER HAS RELIED UPON THE
DECLARATIONS AND STATEMENTS IN THIS APPLICATION FOR COVERAGE. ALL WRITTEN
STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY SUBMITTED IN CONJUNCTION WITH
THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND
MADE A PART HEREOF. NOTHING CONTAINED HEREIN OR INCORPORATED HEREIN BY
REFERENCE SHALL CONSTITUE NOTICE OF A CLAIM OR POTENTIAL CLAIM SO AS TO TRIGGER
COVERAGE UNDER ANY CONTRACT OF INSURANCE. THIS APPLICATION DOES NOT BIND THE
APPLICANT TO BUY, OR THE COMPANY TO ISSUE THE INSURANCE.
THE UNDERSIGNED APPLICANT DECLARES THAT THE STATEMENTS SET FORTH IN THIS
APPLICATION ARE TRUE. THE APPLICANT FURTHER DECLARES THAT IF THE INFORMATION
SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND
THE EFFECTIVE DATE OF THE POLICY, SHOULD A POLICY BE ISSUED, THE APPLICANT WILL
IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES, AND THE COMPANY MAY
WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATIONS OR
AGREEMENT TO BIND THIS INSURANCE.
NOTICE TO ARKANSAS APPLICANTS: “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.”
NOTICE TO COLORADO APPLICANTS: “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 AUTHORIES.”
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: “WARNING: IT IS A CRIME TO PROVIDE BY THE
APPLICANT.”
NOTICE TO FLORIDA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO
INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN
APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY
OF A FELONY IN THE THIRD DEGREE.”
NOTICE TO KENTUCKY APPLICANTS: “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.”
NOTICE TO LOUISIANA APPLICANTS: “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.”
NOTICE TO MAINE APPLICANTS: “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.”
NOTICE TO MINNESOTA APPLICANTS: “A PERSON WHO SUBMITS AN APPLICATION OR
FILES CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN
INSURER IS GUILTY OF A CRIME.”
NOTICE TO NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR
MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT
TO CRIMINAL AND CIVIL PENALTIES.”
NOTICE TO NEW MEXICO APPLICANTS: “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 CIVIL FINES AND CRIMINAL PENALTIES.”
NOTICE TO NEW YORK APPLICANTS: “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,
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.”
NOTICE TO OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING
THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR
FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE
FRAUD.”
NOTICE TO OKLAHOMA APPLICANTS: “WARNING: ANY PERSON WHO KNOWINGLY, AND
WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR
THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR
MISLEADING INFORMATION IS GUILTY OF A FELONY” (365:15-1-10, 36 §3613.1).
NOTICE TO PENNSYLVANIA APPLICANTS: “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 SUBJECTS SUCH
PERSON TO CRIMINAL AND CIVIL PENALTIES.”
NOTICE TO TENNESSEE APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE,
INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE
OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL
OF INSURANCE BENEFITS.”
NOTICE TO VIRGINIA APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE,
INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE
OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL
OF INSURANCE BENEFITS.”
Signature of Owner, Partner, Member, Principal, or Officer Authorized to Sign as Applicant
Applicant’s Printed Name: _________________________________________
Title: __________________________________________________________Date:
Producer Name:_________________________________________________
License #:

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