Sports Program Insurance Questionnaire

Mailing Address - continued

(Badminton, Bicycling, Billiards, Bocce, Canoeing, Cricket, Croquet, Cross Country Skiing, Curling, Fencing, Handball, Horseshoes,
Kayaking, Kite Flying, Lawn Bowling, Racquetball, Rowing/Crew, Running, Shuffleboard, Snowshoeing, Squash, Tennis, Track & Field
Events, Tumbling, Ultimate Frisbee, Volleyball, Wally Ball, Water Polo)

(Exclusions Apply: Caving, Cheerleading, Climbing, Diving, Extreme Sports, Equestrian, Football (tackle), Gymnastics, Hockey, Jai Alai,
Lacrosse, Mountain Biking, Paint Ball, Rock Climbing, Rugby, Skating, Skiing, Wrestling)

Please use Sport Specific Questionnaire for these activities:
Baseball, Basketball, Bowling, Football (flag), Golf, Martial Arts, Soccer, Softball, Swimming/Diving, Wrestling

GENERAL INFORMATION

General Liability – including injuries to participants

4. Please list locations and buildings at each location (List additional locations on separate page)

	Number of Rows	Construction Type	Condition
Enter info

SEXUAL ABUSE - (If located in Illinois, this section MUST be completed. If located in other states, complete only if you desire coverage.)

	Yes	No
1a. On prospective employees and volunteers?
1b. On existing employees and volunteers?

	Yes	No
4a. Abuse and Molestation?
4b. How to recognize the signs of abuse?
4c. What to do if an individual reports someone molested him/her?

	Number
1a. Number of teams participating:
1b. Total number of games:
1c. Approximate number of participants:
1d. Approximate number of spectators:

	Number
1a. Approximate number of participants:
1b. Approximate number of spectators:

	Start Date	End Date
Camp 1
Camp 2
Camp 3
Camp 4

	Day Only	Day & Overnight
Baseball/Softball
Basketball
Bowling
Football (no tackle)
Soccer
Swimming
Tennis
Volleyball
Wrestling
Other (Describe below)

Start Date to End Date

Not-for-profitIncorporated

	Youngest	Oldest
Age

	Male (%)	Female (%)
Age

	Instructors	Participants
Ratio

	Name	Position	Qualifications/Experience/Certification
1
2
3

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2
Building 3

Replacement CostActual CostTotal Value ($)

	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

OPTIONAL PROPERTY COVERAGES

COMMERCIAL AUTOMOBILE INSURANCE

	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

DIRECTORS & OFFICERS LIABILITY AND WORKERS' COMPENSATION INSURANCE

The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.

Questions? 877-244-9090
Kevin Morency | kmorency@morencyinsurance.com

Morency & Associates Inc.
1194 Long Hollow Pike, Gallatin, TN 37066
Fax: 615-452-6580

https://sportsprograminsurance.com/