Beacon Sports Insurance

Applicant Information

Years this entity has been in business:

Years of experience of management staff:

Proposed Effective Date:

Proposed Expiration Date:

General Information

Has any carrier declined, canceled, or non-renewed insurance coverage for this applicant in the past 3 years:

Yes

Have any employees, directors, or officers of the applicant been convicted of any crime within the past 10 years:

Yes

Camps/Clinics

Is coverage requested for camps and or clinics?

Yes

If no, skip this section

Describe any activities other than sports that are available:

If camp is an overnight camp, describe facilities for overnight stays:

Does camp have a cooking facility or prepare meals for participants?

Yes

If yes, please explain?

Team Personnel

Are coaches certified?

Yes

If yes, who certifies the coaches?

Are coaches paid?

Yes

Are officials/referees certified?

Yes

If yes, who certifies the officials?

Do you contract with others for any services or activities, other than offlcials?

Yes

If yes, please expain?

Do you require a certificate of insurance from contracted service providers?

Yes

If yes, please expain?

Do you perform background checks on all employees and staff?

Yes

List the total number of staff including the following:

Coaches/Managers

Game Officials

Volunteer Workers

Other

If any, please expain?

Risk Management

Is there a written safety program for each activity?

Yes

Do you require a signed waiver and release for all activities, including parent or guardian signatures for minors?

Yes

Do you have safety and activity rules posted?

Yes

Do you have written emergency procedures?

Yes

Is safety gear required for appropriate activities?

Yes

Do you require persons to be certified in first aid and CPR and are these certified persons onsite or immediately available at all times?

Yes

If no, how far is the closest EMT response squad?

Do you have guidelines for handling an incident involving a concussion?

Yes

^*If yes, please provide a copy of your guidelines

Is there a written incident report procedure in place?

Yes

Is a log maintained for all reported incidents?

Yes

Expiring Carrier and Loss Information

If you do not currently have insurance, please skip this section

Name of General Liability Carrier:

General Liability Premium:

Any General Liability Losses reported in the past 5 years:

Yes

Name of Accident Medical Carrier:

Accident Medical Premium:

Any Accident Medical Losses reported in the past 5 years:

Yes

Applicant's Statement and Declarations

The applicant declares to the best of his/her knowledge the information contained in this application and all supplements attached to be 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.

Applicant Signature (checking Yes will satisfy a signature):

Yes

If you require Abuse and Molestation or Directors and Officers coverage, please contact us

Sports Program Application