Non Profit Youth Sports Product Application

Applicant may qualify for an INSTANT QUOTE by completing Section I below. All other Section answers will be required prior to binding and are subject to underwriting approval.

I. INSTANT QUOTE INFORMATION

Instant quote is not available for accounts with losses in the past 3 years. If there is loss history, please complete the entire application.

Organization’s Name:

Location Address:*

Street Address Address Line 2 City State ZIP Code

Same as location address

Please Check if Location and Mailing Address are the same.

Mailing Address:

Street Address Address Line 2 City State ZIP Code

Web Address:*

Is this a Non Profit Organization?*

Yes
No

Sports organized, operated, managed, and sponsored by Organization:*

(Check all that apply)

Others (please describe):

Ineligible Sports: diving, gymnastics, hockey, martial arts, rugby, skiing, wrestling, others as determined by the insurer

For all sports, complete as applicable:*

Sport	Number of Participants 14 years of age and under	Number of Participants 15 - 18 years of age	Camps (Overnight Camps are ineligible)	Number of Campers for all sessions	Average number of days for all sessions

Does organization travel overnight? If “Yes,” complete a. through c.*

Yes
No

If “Yes,” complete "A" through "C"

a. How many nights per trip?

b. What is the maximum number of nights per trip?

c. How many trips per year? _

Does the organization own, lease or operate a swimming pool?*

Yes
No

Does organization own, lease or operate athletic fields or facilities?*

Yes
No

If “Yes,” complete "A" through "C"

a. How many acres is the field?

b. What is the square footage of the facility?

c. Are there any outdoor sport courts on the premises?

Yes
No
N/A

i. Total number: $*

ii. Type (check all that apply):

Basketball
Tennis
Volleyball
Other

Does organization operate a concession stand?*

Yes
No

a. Total receipts: $

Property Section

Construction:*

Frame
All other

Protection Class:*

Requested cause of loss:*

Basic
Special

Requested valuation:*

Replacement cost
Actual cash value

Deductible:*

$1,000
$2,500
$5,000

Coinsurence:

80%
90%
100%

Building limit:	Year constructed:	Square footage:

Business personal property:*

Non Profit Directors & Officers/Employment Practices Liability

Total annual revenue:*

II. General Liability

1. Any general liability losses in the past three years?*

Yes
No

If “Yes,” please provide loss runs.

2. Are participants or parents/legal guardians of minor participants required to sign waiver of liability and release forms for all activities?*

Yes
No

3. Are all athletic participants 18 years of age or younger?*

Yes
No

4. Does organization maintain copies of signed waiver of liability and release forms?*

Yes
No

5. Does organization have trips that require them to travel by airplane, train or bus?*

Yes
No

6. Does organization have a written code of conduct or policy of zero tolerance for abusive or unsportsmanlike conduct applicable to all participants?*

Yes
No

7. Are staff or volunteers trained/certified in CPR, first aid or the use of an Automated External Defibrillator (AED)?*

Yes
No

Accident Medical Coverage

(Subject to underwriting approval by licensed accident and health insurer not affiliated with United States Liability Insurance Group)

8. Does organization maintain accident and health coverage for the benefit of participants?*

Yes
No

a. Have there been any accidental medical losses in the past 3 years?*

Yes
No

b. Select accident medical deductible:*

$0
$100
$250
$500

c. Select accident medical limit:*

$25,000
$50,000
$100,000
$250,000

Field & Facility

9. Does organization maintain its fields or facilities?*

Yes
No

If yes, complete 10 and 11

10. Does organization lease its fields or facilities to others?

Yes
No

a. Does organization require those using the fields or facilities to provide certificates of general liability insurance?

Yes
No

11. Do any fields or facilities have bleachers or grandstands?

Yes
No

a. Permanent or portable?

Permnent
Portable

i. If permanent, when were they installed?

b. Are they inspected regularly?

Yes
No

c. What is the construction of the bleachers?

Abuse & Molestation

12. Are background checks regularly conducted on all employees and volunteers (which include sex related or child abuse claims)?*

Yes
No

13. Does organization staff (paid and volunteers) employment application include questions about whether the individual has ever been convicted of any crime, including sex related or child abuse related offenses?*

Yes
No

14. Does organization have written procedures for addressing claims of sexual abuse or molestation?*

Yes
No

15. Does organization have a formal procedure for monitoring employees and volunteers in contact with children, both on and off premises?*

Yes
No

Hired/Non Owned Auto

16. Does organization have a motor vehicle liability insurance policy in place?*

Yes
No

17. Does organization own any motor vehicles or lease any motor vehicles on a long term basis?*

Yes
No

18. Does organization use hired or non-owned vehicles with passenger capacities exceeding 8 passengers?*

Yes
No

19. Does organization use hired or non-owned vehicles for emergency medical transportation or emergency medical services?*

Yes
No

20. Does organization require a minimum of $100,000 CSL or $100,000/$300,000 personal auto liability limits from employees and volunteers?*

Yes
No

III. Property

21. Any property losses in the past three years?*

Yes
No

If “Yes,” please provide loss runs.

22.*

Age of roof (yrs):	Plumbing updated (yr):	Electrical updated (yr):	Heating updated (yr):

23. Roof type:*

Flat
Wood shake
Shingle
Metal
Tile
Slate
Other

24. Plumbing type:

PVC
Copper
Lead
Galvanized
Other

25. Burglar alarm:*

Central station
Local
None
Other

26. Functioning and operational smoke and/or heat detectors in all common areas?*

Yes
No

27. Is all electric wiring on functional and operational circuit breakers?*

Yes
No

28. Is there any aluminum or knob and tube wiring?*

Yes
No

29. Is there commercial cooking on the premises? If “Yes,” complete a through d.*

Yes
No

If “Yes,” complete "A" through "D"

a. Is there a cleaning contract in force with an outside firm?

Yes
No

b. Describe cooking equipment used:

Grills
Open flame
Oven
Deep fat fryers
Charcoal grill

c. Functional and operating fire extinguishing system in place?

Wet
Dry

Type

d. Is the cooking area, hood and duct system protected per NFPA 96 guidelines?

Yes
No

IV. Inland Marine

Schedule of Property & Equipment for which coverage is requested:*

Item	Description	Serial Number	Limit of Insurance	Total Scheduled

Blanket Coverage description (if requesting blanket coverage) - individual items under $2,500 in value:*

Description	Largest Item	Limit of Insurance	Total Scheduled

30. Deductible:*

$1,000
$2,500
$5,000
$10,000

31. Does the insured lease, loan or rent covered property or equipment to others?*

Yes
No

32. Is any insured property or equipment on this schedule left unlocked and/or unsecured when not in use?*

Yes
No

33. Are any objects unique or difficult to replace?*

Yes
No

34. Do any objects have value beyond their apparent worth due to being rare or collectible?*

Yes
No

35. Is all insured’s covered property or equipment brought back to their place of business at the end of each day?*

Yes
No

a. If so, is the place or storage protected by a central station alarm system?*

Yes
No

V. Non Profit Directors & Officers

36. Is the organization involved in product research, development, testing and/or certification?*

Yes
No

37. Does organization engage in any disciplinary actions as a result of peer review activities?*

Yes
No

38. Does organization administer or sponsor any insurance programs?*

Yes
No

39. Is the organization involved in any accreditation or standard setting activities?*

Yes
No

40. Total number of Employees:*

Full time:	Part time:	Volunteers:	Seasonal:

41. Number of members:*

42. Does organization currently carry general liability insurance?*

Yes
No

43. Please provide the following financial information for the last three (3) years. (If organization in existence less than 3 years, please provide budgeted revenue/expense statement for next 3 years)

Year	Total Revenues ($)	Net Income (Loss) ($)	Current Fund Balance* ($)

* Fund balance = Total Assets - Total Liabilities

44. Within the last 5 years, has any inquiry, complaint, notice of hearing, claim or suit been made (including, but not limited to, Equal Employment Opportunity Commission, State Human Rights Boards, Municipal, State or Federal Regulatory Authorities), against the Organization, or any person proposed for insurance in the capacity of director, officer, trustee, employee or volunteer of the organization?*

Yes
No

45. Is any person proposed for this insurance aware of any fact, circumstance or situation, which may result in a claim against the organization or any of its directors, trustees, officers, employees or volunteers?*

Yes
No

If “Yes,” please forward a completed USLI supplemental claims application.

VI. Fiduciary Liability (Available for 100 employees or less)

46. Does each pension plan use an outside investment manager?*

Yes
No

(If “No,” Fiduciary will not be offered.)

47. Does each plan subject to ERISA comply with all applicable requirements of ERISA and the Internal Revenue Code of 1982, as amended (the “Code”) including eligibility, participation, vesting, fiduciary responsibility and funding standards?*

Yes
No

(If “No,” Fiduciary will not be offered.)

If “No,” please attach details:

48. In the past two (2) years has there been or is there now under consideration any material changes to a plan or termination/consolidation of a plan?*

Yes
No

If “Yes,” please attach details:

49. Has there been or is there now pending any claim(s) against any proposed Insured arising out of any plan?*

Yes
No

(If “Yes,” please attach details:

50. Does any proposed insured have knowledge or information of any act, error or omission which might give rise to a claim under the proposed Fiduciary Liability Coverage?*

Yes
No

If “Yes,” please attach details:

VII. Crime Coverage

51. Employee dishonesty:*

a. Number of employees:*

b. Does organization have an annual financial statement prepared?*

Yes
No

c. Is the organization’s bank account(s) reconciled by someone other than the person also authorized to withdraw deposits or transfer funds?*

Yes
No

d. Do checks written by the organization require a countersignature?*

Yes
No

52. Money and securities:*

Limit inside:	Limit outside:

53. Robbery:*

Limit inside:	Limit outside:

54. Safe burglary:*

55. Premises burglary:*

Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application for the policy or otherwise.

Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to “vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.

Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.

Missouri Notice: Pursuant to Section IV, Paragraph R., some Defense Costs are within the Limit of Liability. Any Defense Costs paid under this coverage will reduce the available Limits of Insurance and may exhaust them completely. Defense Costs means reasonable and necessary legal fees and expenses incurred by the Company, or by any attorney designated by the Company to defend any Insured, resulting from the investigation, adjustment, defense and appeal of a Claim. Defense Costs includes other fees, costs, costs of attachment or similar bonds (without any obligation on the part of the Company to apply for or furnish such bonds), but does not include salaries, wages, overhead or benefits expenses of any Insured.

Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside the state of Utah, for which coverage is sought under the same policy.

Virginia Notice: You have an option to purchase a separate Limit of Liability for the extension period, policy common conditions I. If you do not elect this option, the Limit of Liability for the extension period shall be part of and not in addition to the limit specified in the declarations. Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.

Colorado Fraud Statement: 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.

District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida Fraud Statement: 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, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky Fraud Statement: 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.

Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

New York Fraud Statement: 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 purpose 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.

Ohio Notice: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance applications are incorporated into, and shall form part of, this policy. I understand that any material misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or provide the company the right to rescind it.

Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania Fraud Statement: 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 purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Fraud Statement (All Other States): 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.

If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.

Producer Name:*

Retail Agency Name:*

License #:*

Main Agency Phone Number:*

Agency Mailing Address:*

Street Address Address Line 2 City State ZIP Code

The signer of this application acknowleges and understands that the information provided in this Application is material to the Insurer’s decision to provide the requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium charged, based on the Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Insurer and shall not stop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is agreed that this Application shall be the basis of the contract should a Policy be issued and it will be attached and become part of the Policy

Applicant’s Signature:*

(President, Chairperson or Executive Director)

Title:*

Date:

Youth Sports Program Application

Youth Sports Program APP

Non Profit Youth Sports Product Application

Applicant may qualify for an INSTANT QUOTE by completing Section I below. All other Section answers will be required prior to binding and are subject to underwriting approval.

I. INSTANT QUOTE INFORMATION

Property Section

Non Profit Directors & Officers/Employment Practices Liability

II. General Liability

Accident Medical Coverage

Field & Facility

Abuse & Molestation

Hired/Non Owned Auto

III. Property

IV. Inland Marine

V. Non Profit Directors & Officers

VI. Fiduciary Liability (Available for 100 employees or less)

VII. Crime Coverage