Swimming / Diving Insurance Questionnaire

Swimming/Diving Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
Swimming Teams | Swimming Clubs | Swimming Leagues | Swimming Camps | Swimming Clinics | Swim Tournaments | Races
Diving Teams | Diving Clubs | Diving Leagues | Diving Camps | Diving Clinics | Diving Tournaments | Races
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

	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:

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

	Name	Position	Qualifications/Experience/Certification
1
2
3

Swimming/Diving Insurance Questionnaire