Request for quote form must be completed and returned for underwriter review. Submission of this form does not guarantee coverage. Quote will be offered if risk meets Underwriting Guidelines. Payment of premium is required to bind coverage.
Name Insured
Address 1
Address 2
City
State
Zip Code
Country
Fax
Phone Number
Contact Person
Contact Person Email Address
Contact Person Title
Effective Date
Expiration Date
Activity Start Date
Activity End Date
Gross Revenue
Name Insured Is
Individual
Partnership
Corporation
Association
Non-Profit
Other
Coverage Type Requested
Accident Medical
Participant General Liability
Spectator General Liability
Abuse & Molestation (Complete Section D)
Liquor Liability
Hired/Non-Owned Auto
Sports Equipment Coverage (Inland Marine)
Note: If Sports Equipment Coverage (Inland Marine) is selected, a separate form will need to be completed.
Number of est. spectators for all sports/activities insured
Number of est. spectators at each game
How many sessions/games
Type of Organization
Team, League or Association (complete Sections A & C)
Camp, Clinic or Tournament (complete Sections B & C)
Team, League or Association; and Camp, Clinic or Tournament (complete Sections A, B & C)
SECTION A: Team, League or Association Underwriting Information
What is the activity?
- None -ArcheryBadmintonBaseballBasketballBaton TwirlingBowlingBoxingCheerleadingCross CountryDivingFencingField HockeyFootball - FlagFootball - Non Contact Football Football - TackleGolfGymnasticsHandballHikingIce-HockeyIce-SkatingIn-Line SkatingJudoKarate/Martial ArtsLacrossePistolPoloRifleRock ClimbingRodeoRoller HockeyRowingRugbySailingSkateboardingSkeetSkiing-Cross CountrySkiing-DownhillSoccerSoftballSquash/RacquetballSwimmingSurfingT-BallTennisTrackTrapVolleyballWeightliftingWrestlingOther
# of participants age 12 and under
# of participants age 13-15
# of participants age 16-18
# of participants age 19 & over
# of volunteers
# of coaches
# of officials/umpires
Type of Camp, Clinic or Tournament
Day
Overnight
Travel
Sport
Youth
Adult
Special Needs
Please check all that apply. If additional activities are offered, please enter in the "Additional Activities" field below.
Additional Camp, Clinic or Tournament Types
Please list all that apply
Name of Camp and Address of Camp Location
Date Camp Starts
Month
MonthJanFebMarAprMayJunJulAugSepOctNovDec
Day12345678910111213141516171819202122232425262728293031
Year
Year20152016201720182019
Date Camp Ends
# Campers Ages 12 & Under
# Campers Ages 13-15
# Campers Ages 16-18
# Campers Ages 19 & Up
Day or Night Camp?
Underwriting Information
Activity Description *
Describe all activities you are requesting insurance coverage for
Do you require all participants and volunteers to sign waivers?
Yes
No
Do you have procedures for screening employees, coaches, volunteers?
Do you have a written contract with the facilities you utilize?
Are you contractually obligated to name facility owners as additional insured?
Do you currently have Accident Medical Coverage and/or General Liability?
Is Abuse and Molestation coverage requested?
Do you conduct a personal interview?
Do you verify employment related references?
By checking "I Agree," 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. The applicant further understands that a quote will be offered if risk meets Underwriting Guidelines and payment of premium is Named Insured's formal request to obtain insurance through the Young Group. *
I agree
Date
Printed Name *
Title *
