Pullen Insurance Services

Applicant Information

1.	Applicant Company Name:
2.	Street Address:
3.	City:
	State:
	Zip Code:
4.	Contact Name:
	Contact Phone:
	Contact Email:
5.	Website:
6.	Type of Business:	Individual Corporation Partnership Joint Venture Non-profit Organization Other
	If other, please describe:
7.	Requested Effective Date of Coverage:

Athletic Participant Exposure Information

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

Age Group	Sport Played	First Practice Date	Sport End Date	Total Players
12 & under 13-15 years 16-18 years 19 and older
12 & under 13-15 years 16-18 years 19 and older
12 & under 13-15 years 16-18 years 19 and older
12 & under 13-15 years 16-18 years 19 and older
12 & under 13-15 years 16-18 years 19 and older
12 & under 13-15 years 16-18 years 19 and older
12 & under 13-15 years 16-18 years 19 and older

2.

Does the policyholder conduct camps for non-league / member participants?

Yes No N/A

Liability Underwriting Information

1.	Was the organization formed more than three years ago?	Yes No N/A
2.	If applicable, will the standard safety gear for the sport be used?	Yes No N/A
3.	Does the organization require Waiver / Release forms from    all participants or guardians, if appropriate?	Yes No N/A
4.	If not, will you institute a program for Waiver / Release forms?	Yes No N/A
5.	Are cheerleading pyramids ever more than 2 persons high or    are spring boards or trampolines ever used?	Yes No N/A
6.	Does the organization have and enforce written standards regarding    Sexual Abuse and Molestation?	Yes No N/A
7.	Does the organization conduct criminal background checks    on all coaches and staff members?	Yes No N/A
	If yes, are you interested in coverage for claims regarding Sexual Abuse and Molestation?	Yes No N/A

9.

What limits of liability for Sexual Abuse would you like quoted?

$25,000 / $100,000 $100,000 / $300,000 $1,000,000 / $1,000,000 None (Excluded)

Medical Underwriting Information

1.	What accident medical limit (per injury) are you interested in?	$25,000 $50,000 $100,000
2.	What accident medical deductible would you like quoted?	$100 $250 $500 Other

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 N/A
3.	How are league participants transported to events?
4.	Who is responsible for maintaining the field / facilities?
5.	Are the fields/facilities inspected prior to play?	Yes No N/A
6.	Is alcohol permitted at any event sponsored by the Named Insured?	Yes No N/A

Claims History

1.

Current Insurance Carrier:

2.	Is there prior insurance coverage?	Yes No N/A
3.	If yes, when does your current coverage expire?

4.	Has the organization had any general liability and/or    sexual abuse/molestation claims and/or incidents in the last 3 years?	Yes No N/A
5.	If yes, please explain the claim(s).
6.	Has insurance coverage been denied, cancelled or non-renewed    during the last 3 years?	Yes No N/A
7.	If yes, please explain:

Questions / Comments: