Swimming / Diving Insurance Questionnaire

Applicant's Name:*

Address:*

Mailing Address

Address (cont):*

Mailing Address - continued

Contact:*

Email*

Telephone:*

Website

Fax:

Applicant is:

Current Carrier:

Expiration Date:

Limits: ($)

Premium: ($)

Deductible: ($)

GENERAL INFORMATION

1. Liability Coverage (check coverage desired):

General Liability – including injuries to participants

GL Occurrence Limits desired:

GL Aggregate Limits desired:

2. Do you want Abuse & Molestation coverage (available for youth leagues)?

YesNo

3. Participants' medical payments: (select one - diving not eligible)

$1,000$2,500

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

Location 1: Address and number of buildings

Location 2: Address and number of buildings

OPERATIONS

1. Dates of operation:

2. Age of participants/members (check one or both):

Under 1919 or older

3. Please indicate membership or affiliation with any state, national and/or international association/organization:

GENERAL

1. Are the pools?

InsideOutsideBoth

2. Are the pools inspected before every session?

YesNo

3. Who is responsible for maintaining the pool?

4. In the event of unsafe facility conditions, who has the authority to cancel the event?

5. What equipment do you provide?

6. Whose rules and official guidelines do you follow?

7. During swim meets and practices, is a lifeguard, coach or some other qualified official acting as lifeguard?

YesNo

8. Do you require participants to sign a waiver of liability? (If yes, please attach a copy.)

YesNo

SAFETY CHECKLIST - The following guidelines must be met in order to be eligible for coverage:

1. All pools used are approved by the National Swimming Pool Institute and/or the American Public Health Association.

YesNo

2. Pools are equipped with proper depth and lane markings.

YesNo

3. Pools have applicable rules visibly posted for all participants.

YesNo

4. Racing dives or dives from starting blocks are performed in water with a minimum depth of five (5) feet or more.

YesNo

DIVES

1. Is training provided for racing dives?

YesNo

2. When using a starting block, are racing dives only made in water with a depth of 5 feet or more?

YesNo

3. Is diving permitted (other than racing dives)?

YesNo

4. Is there any diving competition?

5. What are the board heights?

6. What is the well depth?

7. Are all dives from one meter or higher performed with a minimum of 10 feet of water in the well?

YesNo

8. Are all dives from 3 meters or higher performed with a minimum of 11 feet of water in the well?

YesNo

9. Is there platform diving?

YesNo

9a. If yes, explain height and control regulations:

RECREATION

1. Are there any slides or anchored floating devices?

YesNo

1a. If yes, please describe:

SPORT FACILITIES

1. Do you own the field/facility?

YesNo

1a. If no, who is the owner?

1b. Is location listed under "General Information"? If not, please list here.

2. Are there bleachers or a grandstand?

YesNo

2a. If yes to bleachers or grandstand:

	Number of Rows	Construction Type	Condition
Enter info

2b. If yes, are there railings on the back and sides?

YesNo

3. Do you sell or rent any equipment to the camp participants?

YesNo

4a. If yes, please describe:

4b. If yes, annual sales amount:

5. Do you sell any food or beverages?

YesNo

5a. If yes, please describe:

5b. If yes, annual sales amount:

6. Are there any non-sport activities?

YesNo

6a. If yes, please describe:

7. Do you host any banquets?

YesNo

7a. If yes, please explain:

MEDICAL ASSISTANCE

1. Is there an accident/medical policy for participants/members?

YesNo

1a. If yes, with what company?

2. Are first aid kits available?

YesNo

3. Is any of your staff certified in:

CPRFirst Aid

3a. If yes, please describe:

4. Other medical help:

4a. Location

4b. Distance

5. Do you have a written crisis/disaster management plan? (If yes, please provide.)

YesNo

6. Do you have a written medical emergency plan? (If yes, please provide.)

YesNo

7. Are annual background checks done on all staff?

YesNo

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

1. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse-related offenses:

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

1c. How often?

2. Does the applicant verify employment/volunteer-related references?

YesNo

2a. If yes, how?

2b. If yes, how often?

3. Does the applicant conduct personal interviews?

YesNo

4. Does the applicant discuss the following items at staff orientation:

	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?

5. Does applicant have supervision plan to monitor staff in day-to-day relationships with clients/children?

YesNo

6. Does the applicant have knowledge of any incident which could give rise to, or result in, an allegation of sexual abuse?

YesNo

6a. If yes, please explain:

7. Has there ever been an allegation of sexual abuse made against the insured?

YesNo

7a. If yes, please explain:

LEAGUES

1. Do you offer leagues?

YesNo

1a. Number of teams:

1b. Total number of games played per season (include playoffs, championships, and tournaments)

1c. Does the league provide umpires, referees, or other officials?

YesNo

1ci. If yes, please explain:

1d. Does the league provide training for officials, team managers, or coaches?

YesNo

1di. If yes, please explain:

1e. Youth Leagues: Are written procedures in place for the prevention of abuse and molestation?

YesNo

1f. Has there ever been any allegation of sexual abuse, misconduct or molestation?

YesNo

1fi. If yes, please explain:

CLUBS

1. Do you offer clubs?

YesNo

1a. Number of members:

1b. Are non-members allowed to participate?

YesNo

1c. Number of events/games/races per year?

1d. Does the club provide any officials?

YesNo

1di. If yes, please explain:

1e. Are there any other activities the club hosts or promotes other than the primary sport?

YesNo

1ei. If yes, please explain:

1f. Do members volunteer time to work for the club?

YesNo

1fi. If yes, please explain:

TOURNAMENTS

1. Do you offer tournaments?

YesNo

Please complete table:

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

RACES

1. Do you offer races?

YesNo

Please complete table:

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

1c. Who will control road traffic to keep racers safe?

	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)

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

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

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

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

	Name	Position	Qualifications/Experience/Certification
1
2
3

Swimming/Diving Insurance Questionnaire