Kristin Rosinus 239-737-3003 Kristin.Rosinus@FDean.com Youth Swim Lesson Application 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 Coverage Start Date * MM DD YYYY Number of Youth Participants * Total number of unique individuals age 17 and under. (If none, please enter 0) Number of Adult Participants * Total number of unique individuals age 18 and over. (If none, please enter 0) Annual Gross Revenue * Does your Organization have any specific insurance requirements? Please list any specific requirements you may have. (If none, leave blank) 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 Does your organization have other sports outside of the selected above? * 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 If Yes, please briefly describe Do you provide lifeguard certification classes? * Yes No Do you provide pool maintenance services? * 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!
