Climbing Walls Insurance Questionnaire

Climbing Walls 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: ($)
GENERAL INFORMATION

Please provide copies of the operations/safety/training manuals, which include procedures for: Equipment/wall inspection, proper belaying techniques/certification, setup and takedown, belay device failure or entrapment, emergencies and reporting problems.
1. Describe your operations including a complete list of activities. Please attach a flier if available.
2. What are the annual gross sales from this operation?
3. How many climbers annually?
4. How many walls are being used? Please provide photos of climbing wall(s).
5. What is the height and width of the climbing wall(s)?
6a. If the walls are portable, how are walls transported?
6b. If the walls are portable, does the operator stay with the walls?

YesNo
7. If walls are stationary, are the walls part of another operation?

YesNo
7a. If yes, what type of operation? (If yes, please submit a Certificate of Insurance for the rest of the risk. )
8. Do all climbers sign waivers? (Please provide copies of waiver, release or consent forms.)

YesNo
9. What is the minimum age allowed?
9a. If under 18 years old, do parents or guardians have to sign the waiver also?

YesNo
10. Do you allow climbers to use personal equipment?

YesNo
10a. If yes, describe your policy with respect to screening of personal equipment used by others:
11. Are all belayers certified/trained?

YesNo
12. What type of belay device is used?

12a. If an auto belay device,

	Enter info below
How old is the device?
Date of last inspection
Who is manufacturer

13. Is there a minimum of 6 to 12 inches of fall protection beneath the climbing wall out to a distance of 6 to 8 feet?

YesNo
14. What type of material is used in the landing area?
15. Is a daily inspection of the wall performed and results documented?

YesNo
16. Is wall maintenance conducted by an independent contractor who provides you with a certificate of insurance?

YesNo
17. Is all climbing safety equipment inspected, with inspection results documented?

YesNo
18. Are safety rules posted? (Please provide rules for the climbing wall.)

YesNo
20. Is a full-time staff member positioned to have a clear view of the climbing wall and participants?

YesNo
21. Do you ever hire sub-contractors/independent contractors that carry their own insurance?

YesNo
21a. If yes, please provide details:
21b. If yes, are certificates of insurance provided?

YesNo
21c. Do you require contractors to name you as additional insured on their policy?

YesNo
21d. Total Cost:

	Enter number below
Concession Receipts ($)
Number of Stands
Square Footage

	Enter Number Below
Ranges
Ovens
Deep Fryers
Grills
Broilers
Griddles

	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?

	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?

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible