Kristin Rosinus 239-737-3003 Kristin.Rosinus@FDean.com Lacrosee Leagues (Youth and Adult) Lacrosse Leagues and Clubs Full Legal Name of the Proposed Policyholder * Type of Organization * Corporation LLC Individual / Sole Proprietor Partnership / Joint Venture Not-for-Profit Other Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Details Contact Person * First Name Last Name Phone * (###) ### #### Email * Website http:// Insurance Information Are you currently insured? Yes No Coverage Start Date * MM DD YYYY Does your Organization have any specific insurance requirements? Please list any specific requirements you may have. (If none, leave blank) Activities Type of Organization Individual Team League Club Regional Organization If your organization participates in any other sports, please list below Description of Activities Please provide a brief summary of all activities. Ex. League Play, Camps, Tournaments, etc. Number of Youth Participants Age 12 and Under * Total number of unique individuals age 17 and under. (If none, please enter 0) If your organization has multiple sports, please provide an estimate of participants per sport. Number of Youth Participants Age 13 - 15 * Total number of unique individuals age 17 and under. (If none, please enter 0) If your organization has multiple sports, please provide an estimate of participants per sport. Number of Youth Participants Age 16 - 18 * Total number of unique individuals age 17 and under. (If none, please enter 0) If your organization has multiple sports, please provide an estimate of participants per sport. Number of Adult Participants * Total number of unique individuals age 18 and over. (If none, please enter 0) If your organization has multiple sports, please provide an estimate of participants per sport. Underwriting Questions Has your past liability coverage been canceled in any way in the last three years? * Yes No Does your organization currently utilize a waiver system? * Yes No Does your organization have a written safety plan or risk management plan in place? (For example: Emergency Procedures, Written/Posted Rules and/or Regulations, Code of Conduct, Consent Form, Emergency Contact Form) * Yes No Is your current insurer non-renewing coverage? * Yes No Have any liability claims been paid by your insurer during the last 3 years? * Yes No Do you own or operate any sports fields, courts or facilities on a 24-hour basis? * Yes No Does your organization have other sports outside of the selected above? * Yes No Is anybody of your players compensated/paid to participate in your sports organization? * Yes No Is your organization school-sanctioned? * Yes No Are any activities held on residential property? * Yes No Do any activities take place at a pool that you own, operate or manage? * Yes No The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this proposal and declares all statements set for herein are true, complete, and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the submission and the insurer’s receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage. It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not applicable until accepted. * Agree Thank you!
