If yes, are certificates of insurance naming the facility as an additional insured obtained?:
Yes No
24.
Is there a system in place for obtaining certificates of insurance where applicable?:
Yes No
If yes, who reviews certificates on behalf of named insured?:
What is the minimum limit of general liability coverage requested from each subcontractor?:
25.
Are child care services provided?:
Yes No
If yes, do you do background checks on individuals providing child care services?:
Yes No
Please explain the services offered and the procedures in place to protect the children while in your care:
26.
Do you have cooking surfaces on site?:
Yes No
If yes, are cooking surfaces properly protected from fire exposures?:
Yes No
If yes, please explain:
27.
Is named insured involved in the sale or distribution of any products?:
Yes No
If yes, please explain:
28.
Are there any special events planned at your facility during the coverage term (e.g. festivals, large tournaments, etc)?:
Yes No
Please explain:
Estimated spectators for these events?:
Automobile
29.
Does the Insured have any owned automobiles?:
Yes No
If yes, who is the insurer?:
Limits of coverage:
Effective date of coverage:
(MM/DD/YYYY)
30.
Do you allow employees to use their own personal vehicles for your business purposes?:
Yes No
If yes, how many employees use their own personal vehicles?:
If yes, how often?:
Daily Weekly Monthly Other:
31.
Do you have a driver screening program for those employees who use their own personal vehicles for your business purposes?:
Yes No
Do you obtain Motor Vehicle Reports?:
Yes No
If yes, how often?:
Annually Every other year Other:
32.
Do you confirm that all employees who regularly use their cars for business purposes carry minimum personal auto limits?:
Yes No
If yes, what minimum limits are required?:
33.
Please provide the approximate cost of hire for all hired or leased autos during the course of the policy period?:
$
34.
Do you have a driver training program for employees who use owned vehicles or their own personal vehicles?:
Yes No
General Questions
Yes No
Are rules posted conspicuously and enforced at all times?
Yes No
Are participants required to wear safety equipment during play?
Yes No
Are participants required to sign a Waiver and Release of Liability? Please provide a copy.
Yes No
Are copies of the Waiver and Release of Liability kept on file? How long?
Yes No
Are the referees or coaches employees of the facility?
Yes No
Are parking lots well lit and patrolled?
Yes No
Are facility inspections done regularly to detect potential hazards? (including restrooms)
Yes No
Is a log kept of inspections and maintenance performed?
Yes No
Are written emergency procedures in place? (attach copy)
Yes No
Do you have any skatepark or BMX operations on site? If yes, are they supervised at all times?
Yes No
Does the facility rent or repair sports equipment?
Yes No
Is the facility locked so that patrons cannot use it when closed? (primary concern is outdoor activity areas)
Yes No
Are there construction operations on site? If yes, is the work subcontracted to a third party with additional insured certificates provided?
35.
Please also provide (quote will not be released until all of these materials are received and reviewed):
loss runs for the past five years (if applicable)
emergency procedures
lease agreement if your facility is not owned
sample waiver and release of liability
sample facility rental agreement
provide a copy of current audited financials
Please read the following terms, conditions and relevant fraud notice below. "Send" button is located at the end of the document.
The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this application and declares all statements set for herein are true, complete, and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the submission and the insurer's receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage.
It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies.
I UNDERSTAND THAT ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION MAY BE SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
Notice to Residents of Arkansas:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
Notice to Residents of California:
I UNDERSTAND THAT ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION MAY SUBJECT THE APPLICANT TO CRIMINAL OR CIVIL PENALTIES.
California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.
Notice to Residents of Colorado:
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the COLORADO DIVISION OF INSURANCE within the DEPARTMENT OF REGULATORY AGENCIES.
Notice to Residents of Delaware:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY.
Notice to Residents of Florida:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE OR, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
Notice to Residents of Kentucky:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURNACE ACT, WHICH IS A CRIME.
Notice to Residents of Michigan:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR CLAIM CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO ONE YEAR FOR A MISDEMEANOR CONVICTION OR UP TO TEN YEARS FOR A FELONY CONVICTION AND PAYMENT OF A FINE OF UP TO $5,000.00.
Notice to Residents of Missouri:
I UNDERSTAND THAT ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION MAY BE SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
Notice to Residents of New Jersey:
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
Notice to Residents of New York:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
Notice to Residents of Ohio:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
Notice to Residents of Oklahoma:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
Notice to Residents of Pennsylvania:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE OR, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
I have read and understand the fraud notice for the state that I reside in.
NOTE: Please print out the application for your own records before clicking on the "Send" button.
Date:
Name of a person completing the form:
Title:
Company:
Email:
Phone:
-
Fax:
-
If printed, return to:
MARK GROSSMAN, PRESIDENT
THE MONUMENT SPORTS GROUP
508 NORTH ALLISON AVENUE, #1
RICHMOND, VA 23220-2704
PHONE: 804-354-9020, FAX: 804-354-9022
E-MAIL:MSG@MONUMENTSPORTS.COM
The Monument Sports Group manages your insurance needs so that you can concentrate on growing your business.