Pullen Insurance Services

Applicant Information

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

Camp / Clinic Participant Exposure Information

1. Please provide the estimated number of camp participants for each anticipated session.

Sport	Day/Overnight	# of Campers	# of Days	# of Camper Days
	DayOvernight
	DayOvernight
	DayOvernight
	DayOvernight
	DayOvernight
	DayOvernight
	DayOvernight

2.

Do you conduct Overnight or Residential Camps?

Yes No N/A

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
8.	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)

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 and/or    Written Regulations?	Yes No N/A
3.	Who is responsible for maintaining the field / facilities?
4.	Are the fields/facilities inspected prior to play?	Yes No N/A

Claims History

1.

Current Insurance Carrier:

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

3.	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
	If yes, please explain the claim(s).
4.	Has insurance coverage been denied, cancelled or non-renewed    during the last 3 years?	Yes No N/A
	If yes, please explain:

Questions / Comments: