Youth Sports Application

Step 2. Complete Application

Submit your application for industry-specific elite insurance coverage.

Applicant Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Business Entity Name(Required)

Affiliate and/or all DBA Name(s)

Location Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your Mailing address same as the Location address?

Yes

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Annual Gross Sales at this location OR if new business provide projected Annual Gross Sales:(Required)

Website

Type of Sport Group(Required)

Entity Type(Required)

Requested Effective Date of Coverage(Required)

Liability Underwriting Information

Please describe the nature of your operations(Required)

Does the organization require Waivers/Release forms from all participants or parent/legal guardian as appropriate?(Required)

Yes

Will you institute a program for Waiver/Release forms?(Required)

Yes

If applicable, will the standard safety gear for the sport be required?(Required)

Yes

Not Applicable

Does your organization have a Code of Conduct, Written Regulations and/or By-Laws?(Required)

Yes

Who is responsible for maintaining the playing fields/facilities?(Required)

Are the fields/facilities inspected prior to play?(Required)

Yes

Does the organization have and enforce written standards regarding Sexual Abuse and Molestation prevention and reporting?(Required)

Yes

Does the organization conduct criminal background checks on all coaches and staff members?(Required)

Yes

What liability limits of Sexual Abuse liability would you like quoted?(Required)

$25,000/$100,000

$100,000/$300,000

$1,000,000/$1,000,000

Other

Have you ever had an incident which resulted in an allegation of sexual abuse?(Required)

Yes

Please provide details about the incident(Required)

Do you distribute a written concussion awareness policy (i.e. CDC’s HEADS UP) to coaches, parents, and players?(Required)

Yes

Does your concussion policy require a medical doctor’s release prior to the child returning to play after a suspected concussion?(Required)

Yes

Do you work with professional athletes?(Required)

Yes

How many professional athletes do you work with?(Required)

Do you have a facility?(Required)

Yes

If yes, how many sq ft?(Required)

Do you own or lease the facility?(Required)

Do you offer birthday parties?(Required)

Yes

If you do so, how many participants?(Required)

Do you have inflatable?(Required)

Yes

If so, how many inflatable you have?(Required)

Do you have batting cages?(Required)

Yes

If so, how many batting cages you have?(Required)

Do you have traverse or climbing walls?(Required)

Yes

If so, how many traverse or climbing walls are under 10 ft?(Required)

How many traverse or climbing walls are under 10 - 20 ft?(Required)

How many traverse or climbing walls are over 20 ft?(Required)

Do you offer soft play?(Required)

Yes

Do you offer zip lines?(Required)

Yes

If so, how many zip lines are under 6 ft?(Required)

How many zip lines are over 6ft?(Required)

Do you offer climbing ropes?(Required)

Yes

If so, how many climbing ropes are under 6 ft?(Required)

How many climbing ropes are over 6ft?(Required)

Do you offer aerial silks?(Required)

Yes

If so, how many aerial silks are under 6 ft?(Required)

How many aerial silks are over 6ft?(Required)

Do you offer trapees?(Required)

Yes

If so, how many trapees are under 6 ft?(Required)

How many trapees are over 6ft?(Required)

Do you have a swimming pool(s)?(Required)

Yes

If so, how many swimming pool(s)?(Required)

Are life guards present?(Required)

Yes

Is there a diving board?(Required)

Yes

If so, how heigh is the diving board?(Required)

Is there a slide?(Required)

Yes

If so, how heigh is the slide(Required)

Is the slide enclosed?(Required)

Yes

Do you have saunas?(Required)

Yes

If so, how many saunas?(Required)

Do you have jacuzzis?(Required)

Yes

If so, how many jacuzzis?(Required)

Do you have tanning beds?(Required)

Yes

If so, how many tanning beds?(Required)

Do you offer cryotherapy?(Required)

Yes

Do you have a booster club(s)?(Required)

Yes

If so, how many booster club(s)?(Required)

Do you offer a child watch service?(Required)

Yes

If so, what is the adult to child ratio for supervision?(Required)

Do you need Hired & Non-Owned Auto coverage?(Required)

Yes

Do you transport participants to or from games, camps, clinics or events?(Required)

Yes

If so, explain how are participants transported:(Required)

The General Liability limits provided will be $1,000,000 per occurrence with $3,000,000 annual aggregate. Do you need higher limits?(Required)

Yes

If so, please explain your General Liability requirements:(Required)

Do you want Professional Liability coverage included?(Required)

Yes

The Premises Rented (Fire Legal) limit will be $100,000. Do you need higher limits?(Required)

Yes

Please chose a Premises Rented (Fire Legal) limit :(Required)

$500,000

$1,000,000

Do you offer Unstaffed Access or 24/7?(Required)

Yes

Do you have video coverage of the both interior and exterior of the premises?(Required)

Yes

If so, for how long do you maintain the videos?(Required)

Medical Underwriting Information for Athletic Participants

What accident player medical limit (per injury) would you like quoted?(Required)

$25,000

$50,000

$100,000

Other

What accident player medical deductible would you like quoted?(Required)

Athletic Participant Exposure Information

Please provide the estimated annual number of participants for each sport and age group for which you would like to provide coverage. Coverage will only be quoted and provided for the sports and age groups you specifically indicate below.

For age group 12 & Under : Please enter Sport Type and Estimated Total Players(Required)

For age group 13-15 : Please enter Sport Type and Estimated Total Players(Required)

For age group 16-18 : Please enter Sport Type and Estimated Total Players(Required)

For age group 19 & Above : Please enter Sport Type and Estimated Total Players(Required)

Camps/Clinics/Special Events Exposure Information

Do you offer camps?(Required)

Yes

If so, how many days do you offer camp?(Required)

How many campers in age group 12 & Under per day?(Required)

How many campers in age group 13-15 per day?(Required)

How many campers in age group 16-18 per day?(Required)

How many campers in age group 19 & Over per day?(Required)

Do you offer clinics?(Required)

Yes

If so, how many days do you offer clinics?(Required)

How many participants in age group 12 & Under per day?(Required)

How many participants in age group 13-15 per day?(Required)

How many participants in age group 16-18 per day?(Required)

How many participants in age group 19 & Over per day?(Required)

Are any camps or clinics over night?(Required)

Yes

If so, how many nights do you offer camps or clinics?(Required)

How many campers/participants in age group 12 & Under per night?(Required)

How many campers/participants in age group 13-15 per night?(Required)

How many campers/participants in age group 16-18 per night?(Required)

How many campers/participants in age group 19 & Over per night?(Required)

Do you offer special events?(Required)

Yes

If so, how many special events?(Required)

Describe the special events:(Required)

Claim History

Is there prior insurance coverage?(Required)

Yes

If yes, who is your current insurance provider/carrier?(Required)

Has the organization had any liability claims (i.e. civil lawsuits) or incidents in the last 5 years?(Required)

Yes

If yes, please explain the liability claims (i.e. civil lawsuits) or incidents:(Required)

Property

Do you want property coverage for your fitness and office equipment?(Required)

Yes

What is the replacement cost of all your office and fitness equipment if replaced brand new (Do not take into account depreciation)?(Required)

The property will be valued by replacement cost as long as insured to 80% of the total value.

Do you want business income coverage? (Business income will cover for loss of income due to a covered property loss. Examples: fire, theft, and vandalism)(Required)

Yes

(only applicable if you purchase property coverage)

Would you like to include coverage for the buildout or improvements made to your space?(Required)

Yes

What was the total cost of the buildout?(Required)

Would you like to include building coverage (only if you own the building)?(Required)

Yes

What is the replacement cost of your building? (*IMPORTANT: Replacement Cost is different than purchase price. We are looking for what it would cost to re-build the building from the ground up)(Required)

Is the entity that owns the gym the same entity that owns the building?(Required)

Yes

Please provide the name of the entity that owns the building(Required)

What type of plumbing is in the building?

What type of plumbing is in the building ( Other )?

What is the roof type?

Flat

Pitched

What year was the building constructed?(Required)

Have there been any updates to Heating? Please provide the year it was updated

Have there been any updates to Electrical? Please provide the year it was updated

Have there been any updates to Plumbing? Please provide the year it was updated

Have there been any updates to Roofing? Please provide the year it was updated

Are there any other tenants in your building besides your gym?

Yes

What type of business(es) are you subleasing to?

Do you have a Central Station Burglar Alarm? (An alarm system that automatically notifies authorities when set off.)(Required)

Yes

What is the square footage you occupy?(Required)

What type of construction is the building?(Required)

Frame – combustible (wood) walls and/or roof

Joisted Masonry – non-combustible walls with wood frame or roof

Non-Combustible – minimal combustible materials in construction of the building

Fire Resistive – reinforced concrete construction, very protected steel and concrete, wind resistive

Would you like to include coverage for backup of sewers and drains?(Required)

Yes

Would you like to include glass coverage?(Required)

Yes

Please provide the number of glass panes (including doors) AND the height & width of each pane(Required)

Width and Length of each pane (Ex: 10 ft x 12 ft)

Would you like to include coverage for outdoor signs? (Signs not attached to the building)(Required)

Yes

What is the value ($) of your sign?(Required)

Applicant's Statement and Declarations

The applicant declares to the best of his/her knowledge the information contained in this questionnaire is true and that no material facts have been suppressed or misstated. The applicant further understands that any false or fraudulent statements or misrepresentations could result in termination or voidance of any insurance contract issued from the information stated herein.

Signature(Required)

Date(Required)

Printed Name(Required)

Title(Required)

Youth Sports Application

Applicant Information

Liability Underwriting Information

Medical Underwriting Information for Athletic Participants

Athletic Participant Exposure Information

Camps/Clinics/Special Events Exposure Information

Claim History

Property

Applicant's Statement and Declarations

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