Ropes Course 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. Describe your operations including a complete list of activities. Please attach brochures, ads or other literature concerning your course and/or services provided.

2. Location of Operation

Street Address, City, State, Zip Code

2a. Please list any associations of which you are a member:

2b. Number of years in business:

2c. Total experience in this type of business:

3. Who designed the course?

3a. Were Certificates of Insurance obtained?

4. Who constructed the course?

5. What year was the course originally built?

5a. What percentage of the course is:

Rows	Percentage of Course
High Element (%)
Low Element (%)

5b. Was the course built to PRCA standards?

5c. Are any Portable Elements used?

5ci. If yes, please describe:

6. Have you made any additions or alterations to the course since its original construction?

6a. If yes, list date of change, type of alteration (or element added), and construction vendor name:

7. How often is the course inspected?

7a. Date of last course inspection by professional firm (Month/Year/Name of firm). Please provide copy of the most recent zip line inspection report.

7b. Have you made the recommended improvements on the course since the last professional inspection?

7c. Do you maintain a written log documenting inspections of the lines and related equipment?

7d. Do you perform daily visual inspections of the course and equipment?

PARTICIPANTS

1. Do you have every participant sign a comprehensive waiver of liability? (Please provide copies of the waiver and release or consent forms.)

1a. Are parents/legal guardians required to sign for minors?

2. Are all participants required to wear gloves and helmets?

3. Are participants harnessed prior to advancing to the top of the course or element?

4. Please complete the table below:

Rows	Enter Number Below
a. Total number of participants anticipated in coming year:
b. Anticipated receipts:
c. Percentage of Participants - Under 18 years old
d. Percentage of Participants - Over 18 years old

5. Please provide minimum and maximum participant height, weight, and age range:

Rows	Minimum	Maximum
Age Range
Participant Height
Participant Weight

5a. Are these weight limits based on the course builders/designers recommendations?

6. Do you provide overnight camps for children 18 years or younger?

7. Total number of instructors (including director):

7a. Is the course director certified?

7ai. Name of Certifier:

7aii. Date of last accreditation class or related courses completed:

7b. How many assistant instructors are certified?

7bi. Name of Certifier:

7bii. If not certified, describe training required:

7c. What is the ratio of participants to instructors:

8. Is the course rented to outside groups or individuals? (If yes, please provide copy of rental contract.)

8a. If yes, do you provide supervision?

8b. Gross receipts from leased periods:

8c. Estimated number of participants of rented course periods

9. Does your business offer any of the following?

Rows	Yes	No
a. Course Design/Construction?
b. Site/Course Accreditation/Certification
c. Instructor Certification?
d. Sale of rope course supplies/accessories?

9di. Types of products sold:

9dii. Are all products in compliance with ACCT standards?

9diii. Estimate product sales per year:

9div.

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

10a. If yes, please provide details

10b. If yes, are certificates of insurance provided?

10c. Do you require contractors to name you as additional insured on their policy?

10d. Total Cost ($):

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

Rows	Enter number below
Ranges
Ovens
Deep Fryers
Grills
Broilers
Griddles

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

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

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

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

Rows	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?

Rows	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible