Pullen Insurance Services

Applicant Information

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

Athletic Participant Exposure Information

1. Please provide the annual number of participants for each sport and age group.

Sport	Age Group	# of Participants	# of Days in Duration
	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

Liability Underwriting Information

1.	Was the organization formed more than three years ago?	Yes No N/A
2.	Do you have trampolines over 46"?	Yes No N/A
3.	If applicable, will the standard safety gear for the sport be used?	Yes No N/A
4.	Does the organization require Waiver / Release forms from    all participants or guardians, if appropriate?	Yes No N/A
5.	If not, will you institute a program for Waiver / Release forms?	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)

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 participants transported to events?
4.	Who is responsible for maintaining the fields / 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: