APPLICATION FOR AMATEUR SPORTS CAMPS & CLINICS

Transcription

1 National Administrator: BENE-MARC, INC. Servicing Agent: Koster Insurance Agency APPLICATION FOR AMATEUR SPORTS CAMPS & CLINICS Instructions The Applicant is required to complete sections 1, 3, 7, 8 and 405C Terrorism form. If additional coverages are desired, indicate so and complete the corresponding section(s). Additional information and premium will be required for any optional coverage(s). The following are requirements for underwriting your application: a) Completed Application signed and dated; and b) Completed Terrorism Form, (405C) signed and dated; and c) Copy of your waiver/release form; and d) If you own your premises send a copy of your current premises liability coverage; and e) Proof of liability coverage for any other sports/events that will not be covered under this policy; and f) Surplus Lines Affidavit if applicable; and g) Application MUST be received at least 15 days before requested effective date. SECTION 1 GENERAL INFORMATION (All Applicants must complete this section. PLEASE PRINT) 1. Are you a: LLC Corp. Partnership Individual Nonprofit Corp. Other (specify) 2. Legal Entity Name (If you did not check Individual): 3. Camp Name: 4. Physical address: (You may use your home address.) 5. City: State: Zip Code: 6. Mailing address (If different from Camp/Clinic address): 7. City: State: Zip Code: 8. Contact person name: 9. Phone numbers: Evening: ( ) Day: ( ) Cell: ( ) Fax: ( ) 10. Address: 11. Camp/Clinic Website: SECTION 2 ADDITIONAL INSURED(S) (Complete ONLY if applying for liability coverage) Only list those entities that contractually require you to name them as an additional insured on your General Liability policy. We will only honor such requests that are made by the Insured s contact (as completed in Section 1.) Note that the certificates will not be sent directly to these entities they will be sent to you for delivery. (If you do not provide the complete mailing address of the Additional insured(s), we will not be able to issue the certificate.) Your insurance premium includes 2 additional insured(s). Issuance of 3 or more additional insured(s) will result in an additional $25 per additional insured. 1. Name: 2. Name: Address: Address: City/St/Zip: City/St/Zip: Interest to insured: Interest to insured: (Ex. Landowner, field location, sponsor) (Ex. Landowner, field location, sponsor) (If additional names are needed, provide on a separate piece of paper.) Bene-Marc Use Only: (Ed ) Agent s Initials: Underwriter Review / Approval: PID # Policy # Page 1 of 5

2 SECTION 3 POLICY INFORMATION (All Applicants must complete this section) 1. I need an Annual Policy OR I need a Short-Term Policy (Short-Term policy premiums are fullyearned at policy inception; except in NH and NJ.) 2. I need insurance coverage from / / to / /. 3. Please describe the primary camp/clinic sport or activity: 4. Do you have any other sports or activities that your organization promotes, sponsors, or provides other than the ones listed above? 5. Are these activities covered by another insurance policy? (e.g. special event coverage) Yes No 6. Previous carrier: Bene-Marc, Inc. Other: Liability Medical 7. Age range of your camp participants: 12 & Under Over Do you own or lease the premises used for the operations conducted? ( e.g. school, city, field, own location) 9. Has the type of insurance being applied for been: Cancelled Declined Non-Renewed N/A If any item is checked, except N/A, please explain: 9. Have you held any camps under another name in the past 3 years? Yes No If yes, what was the name and why did you change the name? 10. How long have you been a head coach, director, etc. of a sports program? Less than 3 Years 4-10 Years 11 or More Years 11. If less than three years, please list in detail your experience: 12. Do you sell or rent sports equipment? (e.g. batting cages, pitching machines, etc.) Yes No If yes, please explain: 13. Is your Camp/Clinic affiliated in the distributing or selling of any nutritional supplements? Yes No If yes, please explain: 14. Do you sell any products (e.g. Sports equipment, clothes, Books) If yes please provide total sales. $ SECTION 4 SPORTS EQUIPMENT OPTIONAL COVERAGE NOTICE: Attach a schedule of any equipment that exceeds $1,000 per item & include serial number, year, model and make. Failure to provide this information could result in the denial/reduction of your claim. 1. What type of equipment is to be covered? (e.g. baseball uniforms, soccer balls, goals, etc.) 2. Where is the equipment stored? (We MUST have a complete address including city, state and zip code) Location Name: Facility type: (e.g. rented storage facility) Physical Address: City / State / Zip Code: 3. Sports Equipment Premium Calculation ($25,000 Maximum Limit/$ Deductible per claim) Rate is $1.75 per $100 of equipment s replacement cost value. Policy minimum premium is $ EXACT Equipment value (to be insured) $ X.01 = $1.75 = ($150 Minimum) Page 2 of 5

3 SECTION 5 NON-OWNED AUTO LIABILITY OPTIONAL COVERAGE (Not Available in Illinois) Coverage is available with standard limit of $50,000. Higher limits are available, if qualified, for additional premium. 1. Are any vehicles owned or leased by your organization? Yes No (If yes, coverage cannot be considered) 2. Do your employees or volunteers use their own vehicles on your behalf in the course of their duties? Yes No If yes, please indicate number of Employees Volunteers Please provide details of responsibilities (e.g. errands, participant/child transport). 3. Are DMV driver license checks reviewed prior to approval of any driver? Yes No (This is a requirement) 4. Do you have written standard for eligibility? Yes No If yes, please describe: (This is a requirement for coverage. We will need a copy of the written procedures in place.) 5. Do you have procedures verifying that all drivers carry liability insurance on their personal vehicles? Yes No If yes, please describe: (This is a requirement for coverage. We will need a copy of the written procedures in place.) 6. A requirement for non-owned auto coverage is that the personal auto(s) being used on your behalf carry a minimum of $50,000 in auto liability coverage. Are the autos in question insured with at least $50,000 or greater? Yes No If you have greater than $50,000 in coverage, please tell us the exact limit of coverage that the auto(s) are insured for SECTION 6 SEXUAL MOLESTATION OPTIONAL COVERAGE (Complete this section ONLY if coverage is desired. Limits are available, if qualified, for additional premium, subject to underwriting approval.) The Insurance Carrier requires that you implement procedures for coverage to remain in effect. 1. Is there a written and comprehensive physical/sexual assault awareness and prevention program in place? (If no, sample procedures may be obtained from Bene-Marc so you may implement this program.) 2. Are background and experience checks, including pre-employment screening to screen out individuals not suited for working with minors, completed for all personnel (staff, coaches, volunteers, etc.)? (This is a requirement for coverage.) 3. Does formal training/certification for all personnel (staff, coaches, volunteers, etc.) include specific and detailed training relating to physical/sexual assault and detection? (If no, sample procedures may be obtained from Bene-Marc so you may implement this program.) 4. Are specific and written procedures in place for the reporting and subsequent handling of suspected cases of physical/sexual assault? (If no, sample procedures may be obtained from Bene-Marc so you may implement this program.) 5. Have there been any prior claims or incidents of alleged physical/sexual assault? (If yes, provide details below.) Yes No Page 3 of 5

4 SECTION 7 PRIOR LIABILITY CARRIER LOSS INFO (All Applicants must complete this section) There have been no claims against the organization, team members, coaches, league, sports equipment property coverage or directors and officer s coverage under previous general liability policies for the past three (3) years. There has been a LIABILITY claim, within the last 3 years, against our previous policy. (Complete the table below for claims information. Describe in detail on a separate sheet of paper any one claim within the last 3 years. ALL three years information must be completed if ANY claim has been paid. Do not leave any space blank.) Year Carrier Premium # of Claims Claim Amount Paid SECTION 8 APPLICANT S STATEMENTS AND DECLARATIONS (All Applicants must complete this section) The Applicant(s) declare(s) that to the best of his/her (their) knowledge, the information contained in this Application is true; and that no material facts have been suppressed or misstated. The Applicant(s) further understand(s) that any false or fraudulent statements or misrepresentations may result in termination or voidance of any insurance contract issued from the information stated herein. By signing below I fully understand that remitting this application and premium does not constitute binding of coverage and I further understand that Bene-Marc, Inc. must approve my application before coverage can be bound. I understand that Bene-Marc, Inc. has the right to deny my application and return premium, and if it does so, I will be notified in writing and the premium I submitted, will be returned. By signing below I fully understand that I am placing my liability coverage with a Surplus Lines Carrier rated A+VIII (Superior) by AM Best. I also understand that the surplus lines market is an insurance market that was established for the purpose of insuring unique or hard to place risks. Some of the rules that apply to surplus lines companies differ from those that are govern coverage obtained from companies licensed in your state (except New Hampshire). Since the surplus lines insurer is unlicensed, the transactions are regulated by the state law that requires that surplus lines policies be obtained by special licensed excess or surplus lines agents or brokers who are authorized to transact business with non-admitted insurers that meet certain financial; and other criteria. General Liability Policy Written by: SURPLUS LINES CARRIER Rated A+ VIII (Superior) by AM Best Excess Accident Policy Written by: THE HARTFORD - Alpharetta GA AIG - Dallas, TX Fairmont Insurance Irving, TX Plan Administered by: BENE-MARC, INC. Fort Worth, TX Signature Date Printed Name & Title Page 4 of 5

5 Once Completed, please sign and return to: Koster Insurance Agency Sports & Special Risk Accounts 500 Victory Road Quincy MA Phone: Fax: Page 5 of 5