Insuring the world s fun

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1 MOTORSPORTS Facilities & Events Eligible Operations: - Boat racing - Short track oval - Demo derbies racing - Drag racing - Racing associations - Independent car - Road courses club activities - Snowmobile - Indoor karting competitions - Kart racing - Specialty motorsports - Motorcycle racing events - Motorsports - Super speedways country clubs - Tractor/truck pulls - Motorsports driving schools Key Underwriting/Qualifying Factors (Including but not limited to): - Must meet K&K motorsport insurability guidelines Ineligible for this program: - Noncompetitive participation facilities (i.e., go kart concession tracks, off-road vehicle parks, mud parks) - Drag boat racing K&K Benefits: - Experienced & professional staff dedicated exclusively to servicing the K&K Motorsports Programs for over 65 years - Attendance at industry conventions including RPM Promoters Workshops, Performance Racing Industry Trade Show (PRI) - Active industry involvement through sanctioning bodies, racing associations and event attendance - In-house underwriting, policy administration, loss control and claims services - 24-hour emergency claims phone service - Insurance carriers rated A or higher by A.M. Best - Premium installment plans available No other organization has the knowledge and experience that allows K&K to provide superior coverage for world-renowned racing organizations as well as local tracks, teams and drivers. K&K Insurance has provided motorsports insurance to the industry since 1952 and is still the leader in the industry today. A wide range of products are available to protect motorsports facilities and/or event promoters. From liability and participant accident coverages to property and commercial auto coverages, K&K has it covered. Programs are available to cover facility operators, specialty event promoters and sanctioning organizations. Coverages Available & Program Highlights: General Liability - No General Aggregate - Separate Limits for Legal Liability to Participants - Expanded Bodily Injury Definition - Personal and Advertising Injury Definition Expanded - Official Vehicle Physical Damage - Motorsports Errors & Omissions - Customized Motorsport Policy Language - Host Liquor Liability - Cyber Risk ($25,000 sublimit) Participant Accident Coverage - Accidental Death & Specific Loss - Accident Medical Benefits Available on Excess or Primary Basis - Limits up to $1,000,000 - Volunteer- Accident Medical Coverage for Motorsport Volunteers - Weekly Accident Income Property Crime Inland Marine Commercial Auto Liquor Liability Excess Liability Event Cancellation & Non-appearance Workers Compensation Additional Products: - Contingency/Prize - High Limit Disability Indemnity - Products Liability - Employment Practices Liability Insuring the world s fun

2 Submission Instructions: To request an insurance quotation through this program, please submit the appropriate applications along with the preliminary underwriting information listed. In some cases, requested coverages may not be offered or available due to underwriting criteria and/or carrier guidelines. It is important to carefully review the terms and conditions of any insurance quotations received. Please contact a K&K representative if you have any questions. Preliminary Underwriting Information Required: - K&K Application(s) (see below) - ACORD application(s) for other requested coverages - Five years of company loss runs - Diagram of event locations - Schedule of events - Copies of contracts where insured assumes liability of others Contact Information: 1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN Motorsports Facilities & Events Program PHONE: FAX: KK.Motorsports@kandkinsurance.com WEB SITE: kandkinsurance.com Motorsports Facilities & Events Application(s): (Applications can be obtained from our web site: kandkinsurance.com) K&K Application(s) - Motorsport Facilities Application (if needed) - Property Insurance Questionnaire (if needed) - Premises Liability Insurance Application (if needed) - General Application (if needed) - Permanent Facility Event Enrollment Form (if needed) - Temporary Event Motorsports Enrollment Form (if needed) - Liquor Liability (if needed) - Fireworks Application- Motorsports (if needed) ACORD Application(s) - Property - Commercial Auto - Crime - Inland Marine - Excess Liability K&K Insurance Group, Inc. is a licensed insurance producer in all states (TX license #13924); operating in CA, NY and MI as K&K Insurance Agency (CA license # ) Insuring the world s fun 2/17

3 GENERAL APPLICATION Name of Insured (as will appear on policy): Doing Business As: Mailing Address: City: State: Zip: Phone: ( ) Location Address (if different from above): City: State: Zip: Phone: ( ) Contact Person: Person is: Owner Promoter Agent Other: Day Phone: ( ) Night Phone: ( ) Fax: ( ) Address: Web Site Address: Name of Agency/Brokerage (if applicable): Contact Person: Mailing Address: City: State: Zip: Phone: ( ) Fax: ( ) address: Tax ID: Nature of operations/description of event: Insured is: Corporation Partnership Joint Venture Other (explain): Limited Liability Corporation In what state is the organization headquartered/chartered? Policy period requested: From To Estimated number of events: COVERAGE INFORMATION Check the type of coverage and indicate the limits desired: General Liability Primary Excess Legal Liability To Participants Participant Accident and Health AD&D (Applicable only to Motorsports) Primary Medical Excess Medical Weekly Disability Income Property Casualty Property Inland Marine Auto Workers Compensation Other: /03

4 UNDERWRITING INFORMATION 1. Has this type of insurance ever been: Cancelled Declined Non-renewed If so, please explain. (Not applicable in Missouri). 2. Does this organization 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. 3. As respects your operation(s), do you enter into any contracts? Yes No If yes, what contracts do you enter into? a. Does the Named Insured assume liability for the other party? Yes No PLEASE PROVIDE COPIES OF ALL CONTRACTS OF THIS TYPE. b. Does the other party assume the Named Insured s liability? Yes No PLEASE PROVIDE ONE SAMPLE OF THIS TYPE. c. Does each party assume its own liability? Yes No 4. Who reviews the contracts prior to signing? Corporate Officers Counsel Other (please explain) 5. For each of the following, please indicate if there is a procedure in effect for obtaining certificates of insurance, the limits required for each and whether the certificates list the Named Insured as it will appear on the policy as an Additional Insured. CERTIFICATES LIMITS ADDITIONAL INSURED (Provide copies.) Food Concessionaires Vendors/Exhibitors Contractors/Others 6. Is a K&K approved Waiver and Release form read and signed by all persons entering a restricted area prior to entry? (Applicable only to Motorsports) Yes No PRIOR CARRIER INFORMATION (NEW BUSINESS ONLY) YEAR PREVIOUS AGENT COMPANY LIABILITY LIMITS PREMIUM LOSSES PLEASE SUBMIT A COPY OF PREVIOUS/PRESENT POLICY(IES) I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. Applicant s Signature Applicant s Name (print) Date (MM/DD/YY) Producer s Signature (if applicable) Producer s Name (print) Date (MM/DD/YY) /03

5 1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN (877) Fax (260) CA# INDOOR KARTING OPERATIONAL QUESTIONNAIRE Applicant Name: Web site: OPERATION INFORMATION 1. Business Hours: 2. Programs offered: groups racing programs team building other (please list) 3. Minimum age of participant: Please list any other age restrictions: 4. Minimum height of participant: Please list any other height restrictions: 5. List personal safety equipment required: (helmets, head sock, racing suit, gloves etc.) 6. List personal safety equipment required supplied by you: 7. Describe pre-session training: 8. Is a licensing program in place? Yes No 9. Provide projected receipts for all activities: Karting $ Liquor $ Concessions $ Restaurant $ Arcade $ $ Conference/Party Room $ $ 10. Provide Financials $ 11. Is an employee handbook available? Yes No If Yes, please provide a copy 12. Provide diagram of track showing the following: a. Barrier type and locations. b. Fire extinguisher locations. c. Fuel storage tank location (for gas karts). d. Battery re-charge stations (for electric karts). e. Spectator viewing areas with protection /08

6 13. What is the age of building: 14. What is the size of building: s.f. 15. Size of area used for karting: s.f. 16. Is there a procedure for maintenance and cleaning of karting area? Yes No If Yes, please describe: 17. Kart manufacturer: 18. Gas Electric 19. Are customer karts allowed? Yes No 20. Top speed of adult karts: mph Minimum age 21. Top speed of youth karts: mph Minimum age 22. Is there at least one fire extinguisher within 70 feet from any point on track? Yes No 23. Total number of karts: 24. Number on track at any one time: 25. Number of on track monitors: 26. Are all of the moving engine parts guarded to prevent hair entanglement? Yes No 27. Provide kart maintenance schedules 28. Provide copy of posted rules and regulations. 29. Does each kart have a manufacturer approved gas (if gas) filler cap? Yes No 30. Is building air exchange system in place? Yes No 31. What is the air exchange rate per hour? 32. How often is air quality checked? 33. Explain refueling/recharging procedures and location: 34. Is battery recharge area ventilated? Yes No ANCILLARY ACTIVITIES: Restaurant / Snack Bar Not applicable 1. What is the food and beverage exposure? Full Service Snack Bar Sub-contracted (Lessor s Risk only) 2. Indicate which of the following apply and the number of each: Ranges Ovens Deep Fryers Grills Broilers Griddles 3. Are all cooking surfaces properly fire protected? Yes No 4. Are portable K fire extinguishers provided in the kitchen? Yes No 5. What type of Automatic Extinguishing System (AES) is in place? Wet Dry 6. Do you have a contract for servicing and maintaining the Automatic Extinguishing System? Yes No 7. How often is the serviced and maintained? Monthly Quarterly Semi-Annually Annually /08

7 8. Do you have a contract for cleaning hoods and ducts? Yes No 9. How often are hoods and ducts cleaned? Monthly Quarterly Semi-Annually Annually 10. How often are filters cleaned? 11. Will beer or liquor be sold? Yes No Who holds the valid license? Total liquor receipts: $ Total food receipts: $ Do you obtain certificate from third party? Yes No 12. Have all alcohol servers had alcohol awareness training? Yes No 13. Explain alcohol / driving controls: Climbing Walls Not applicable 1. Who built the walls? 2. What safety equipment will participants be using? 3. Is there some type of safety back-up (describe)? 4. How many participants are anticipated during policy period? 5. Please provide a copy of any waiver/release you propose to use. 6. Please provide diagram and photos of the wall along with any brochures produced. 7. Provide manufacturer name and age of harness equipment. 8. Provide picture of base fall protection. 9. Is belay system manual or automatic? 10. What is the wall height? 11. How many climbers will wall accommodate at one time? Zip Lines Not applicable 1. Who constructed the line? 2. How often is the line inspected? Monthly Quarterly Semi-Annually Annually By whom? 3. Please provide a copy of any waiver/release you propose to use. 4. Please provide photos of the line along with any brochures produced. 5. Provide copy of rules and regulations, and pictures of start point signage. 6. List all other amusement devices on site: By signing this questionnaire the undersigned declares, to the best of his/her knowledge, all statements to be true, complete and accurate. The completion and submission of this questionnaire shall not be binding to the prospective insured or the company until coverage is confirmed bound by the insuring company. Applicant s Signature Date /08

8 1712 Magnavox Way P.O. Box 2338 Fort Wayne, Indiana (800) Fax (260) CA # PROPERTY INSURANCE QUESTIONNAIRE GENERAL INFORMATION Named Insured: Contact Person: Mailing Address: Title: Phone ( ) Fax ( ) Property Location #1: Property Location #2: Prior/Current Insurance Carrier: Prior Losses/Claims: Expiration Date of Current Policy: Years in Business: PROPERTY Amount of Insurance Coverage for: Replacement Cost Actual Cash Value Deductibles: Coinsurance: Limits: Building #1: Contents #1: Building Construction Type: Year Built: Area: Type of Fire/Burglar Protection: Location: Limits: Building #2: Contents #2: Building Construction Type: Year Built: Area: Type of Fire/Burglar Protection: Location: Limits: Building #3: Contents #3: Building Construction Type: Year Built: Area: Type of Fire/Burglar Protection: Location: Limits: Building #4: Contents #4: Building Construction Type: Year Built: Area: Type of Fire/Burglar Protection: Location: page 1 of 5

9 SIGNS (list and describe signs not attached to buildings): GLASS (Panes worth more than $1,000 and all Thermal, Double and Triple Pane glass-list # of panes, width and height of each): BUSINESS INCOME Business Income coverage is an extension of Property Coverage that will pay for the actual loss of Business Income you sustain due to the necessary suspension of your operations during the period of restoration. The suspension must be caused by direct physical loss of or damage to property at the premises described in the policy subject to any applicable exclusions. Please indicate if you are interested in this coverage: Yes No BUSINESS AUTO Liability Coverage: Combined Single Limit: We will automatically include Uninsured/Underinsured Motorist and Medical Payments coverages unless noted otherwise. List of Vehicles: Deductibles* Where Year Make/Model VIN Number Cost New* Comprehensive / Collision Garaged ** * Cost New and Deductibles are needed when insuring the vehicle for Comprehensive and Collision Physical Damage coverage. ** Garaging needs to list City, State and Zip Code. If all vehicles are garaged in the same location you may only list once page 2 of 5

10 Non-Owned/Hired Auto Liability Limit: Number of Employees Hire Care Physical Damage Limit: Deductible: Comp. Collision: CRIME Form A (Employee Dishonesty): LImit: Deductible: Form C (Theft, Disappearance & Destruction): Inside Limit: Outside Limit: Deductible: Deductible: Form Q (Robbery & Safe Burglary-Money & Securities): Inside Limit: Outside Limit: Deductible: Deductible: Explain Security/Safe Protection: WORKERS COMPENSATION Employer s Liability Limits: $ Each Accident $ Disease - Policy Limit $ Disease - Each Employee RATING INFORMATION Categories/Duties/ Number of Est. Annual Job Classifications Employees Remuneration Individuals Included/Excluded: Partners, Officers, Relatives to be included in or excluded from coverage (To be included Remuneration must be part of rating information section.) Date Title/ Incl./ Name of Birth Relationship Ownership % Excl page 3 of 5

11 General Information: 1) Do you have any Seasonal Help? Yes No If yes, how many: 2) Is there any Volunteer or Donated labor? Yes No If yes, how many: 3) Are subcontractors used? Yes No If yes, are certificates of insurance on file? Yes No INLAND MARINE (Equipment that can be taken off-premises including Mobile Equipment not included as Contents under the Property Coverage. For Race Teams, include the competition vehicle, tools, misc. equipment and spare engine that leave your premises.) Scheduled Miscellaneous Articles Limit: Deductible: Equipment Schedule: Number Year Make/Model ID Number Value Large items with significant value should be scheduled above. Unscheduled Miscellaneous Articles Limit: Amt. of Most Valuable Item: Deductible: Limit should include smaller value items such as tools. Electronic Data Processing equipment Limit: Deductible: Equipment Schedule: Number Year Make/Model ID Number Value page 4 of 5

12 LOSS HISTORY Enter all claims or occurrences that may give rise to claims for the prior 5 years. Check here if none See attached loss summary Date of Type/Description of Date of Amount Amount Occurrence Occurrence or Claim Claim Paid Reserved I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. Applicant s Signature Applicant s Name (print) Date (MM/DD/YY) Producer s Signature (if applicable) Producer s Name (print) Date (MM/DD/YY) page 5 of 5

13 ASSETS CURRENT ASSETS Cash and cash equivalents Marketable securities (readily sellable) Accounts receivable Inventories Deferred income taxes Prepaid expenses and other current assets 1712 Magnavox Way Fort Wayne, Indiana (800) Fax (260) CA# Valuation Date: FINANCIAL REPORTING FORM LIABILITIES AND SHAREHOLDERS EQUITY CURRENT LIABILITIES Short-term borrowings Trade accounts payable Other current liabilities Income taxes payable Current maturities of long-term debt TOTAL CURRENT ASSETS TOTAL CURRENT LIABILITIES PROPERTY, PLANT AND EQUIPMENT Land and land improvements Building and improvements Construction in progress Machinery and other equipment Leasehold improvements Accumulated depreciation and amortization LONG-TERM DEBT SHAREHOLDERS EQUITY Paid-in capital Retained earnings Accumulated other comprehensive income (loss) OTHER ASSETS Deferred income taxes Miscellaneous other assets TOTAL ASSETS TOTAL LIABILITIES AND SHAREHOLDERS EQUITY NET SALES Costs and expenses: Cost of sales Selling, general and administrative expenses Operating Income Other income (expenses): Interest and dividends Interest expense Other income Income before income taxes Income taxes NET INCOME 1. Have you ever gone through bankruptcy or had a judgement against you? Yes No 2. Are any assets pledged or debts secured? Yes No The foregoing statement, submitted for the purpose of obtaining insurance, is true and correct in every detail and fairly shows my financial condition at the time indicated. I will give you prompt written notice of any subsequent substantial change in such financial condition occurring before discharge of my obligations to you. I understand that you will retain this personal financial statement whether or not you approve the insurance in connection with which it is submitted. K&K Insurance Group, Inc. is authorized to verify any information contained herein including but not limited to my credit and employment history and to request, obtain, and use credit information on me in the processing of my application. This document, or any photostatic copy hereof, hereby authorizes any third party to furnish to K&K Insurance Group, Inc. with complete consumer credit reports. THE UNDERSIGNED CERTIFY THAT THE INFORMATION CONTAINED ON THIS FORM HAS BEEN REVIEWED AND THAT IT IS TRUE AND CORRECT IN ALL RESPECTS. Signature Date Name (print) /04

14 MANDATORY SIGNATURE SUPPLEMENT TO ALL APPLICATIONS, QUESTIONNAIRES, & ENROLLMENT FORMS THE NOTICES CONTAINED ON THIS SUPPLEMENT APPLY TO ALL UNDERWRITING INFORMATION BEING SUBMITTED TO K&K INSURANCE GROUP, INC., INCLUDING APPLICATIONS, QUESTIONNAIRES AND ENROLLMENT FORMS, FOR THE FOLLOWING PERSON OR ENTITY: Applicant name: Applicable in AL, AR, DC, LA, MD, NM, RI and WV Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO 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. Applicable in FL and OK 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 (of the third degree)*. *Applies in FL Only. Applicable in HI For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Applicable in KS Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA 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* (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only. Applicable in MA, NE, and VT Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. Applicable in ME, TN, VA and WA 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 and denial of insurance benefits. *Applies in ME Only. Applicable in MN Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Applicable in NJ Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. FRAUD APPS (2016/04) I understand that K&K Insurance Group, Inc., for the insuring company, shall be permitted but not obligated to inspect a proposed insured s, or an insured s, property and operations for underwriting purposes at any time. Neither the right to make an underwriting inspection nor the making thereof nor any report thereon shall constitute an undertaking, on behalf of or for the benefit of any insured, or other, to determine or warrant that such property or operations are safe or healthful, or in compliance with any standards, rules or regulations. Underwriting inspections when conducted are for the sole purpose of determining and/or improving the insurability of certain property and operations and not safety. I also understand that an insured is solely responsible for the safety of its facilities and operations and shall not rely upon any underwriting inspections to determine the safety of its facilities or operations and shall not diminish or forego its own safety practices and procedures. I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. I also understand that no insurance will be in effect unless and until the insurance company, or K&K as its agent, provides a quotation offering to provide insurance coverage and the insurance company, or K&K as its agent, receives written notice that the terms and conditions contained in the insurance quotation provided are accepted. APPLICANT S SIGNATURE FRAUD WARNING PRODUCER S SIGNATURE (if applicable) PRINT NAME DATE (MM/DD/YY) PRINT NAME DATE (MM/DD/YY) /16