SODA Facilities Insurance – Application for Quote Step 1 of 6 16% Contact Information New or Renewal* New Customer Renewing Customer Full Legal Name Of Proposed Policyholder:* As it should appear on the policy - legal name of the business/organization - DO NOT use abbreviations. Do not use the contacts name unless you are a sole proprietor. Entity Type:* CorporationLLCPartnershipIndividualMunicipalityHealth ClubOther Are you a non-profit organization?* Yes No Main Location Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the mailing address the same as the main location address?* Yes No Mailing Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Authorized Contact Name:* Daytime Phone* Cell Phone Email:* Website: Facebook URL: Insurance And Loss History Any policy been cancelled or non renewed in past 3 years?* Yes No Please explain policy and reason:* Losses under any policy in past 3 years?* Yes No Please explain policy type, give brief description of claim, approximate date, and amount paid:* Accident Policy - Current Carrier: Accident Policy - Current Premium: General Liability Policy - Current Carrier: General Liability Policy - Current Premium: Select Requested Effective Date, Policies To Be Quoted, Limits Requested Effective Date: Date Format: MM slash DD slash YYYY Do You Wish To Receive A Quote For Accident Coverage?* Accident coverage pays medical bills on behalf of injured participants. I wish to receive a quote for accident coverage. I do not wish to receive a quote for accident coverage. Accident Coverage Medical Limit:* $10,000$25,000Declined Quote Accident Coverage Deductible:* $0$100$250Declined Quote Do You Wish To Receive A Quote For General Liability?* General Liability covers certain lawsuits alleging bodily injury to a spectator or participant, property damage, or personal/advertising injury. I wish to receive a quote for General Liability coverage. I do not wish to receive a quote for General Liability coverage. Each Occurrence Limit:* $1,000,000$2,000,000$3,000,000$4,000,000$5,000,000Declined Quote Do You Wish To Receive A Quote For Directors & Officers Liability?* Directors & Officers Liability covers certain lawsuits alleging discrimination; wrongful suspension or termination; and failure to follow own rules or bylaws. I wish to receive a quote for Directors & Officers Liability coverage. I do not wish to receive a quote for Directors & Officers Liability coverage. Do You Wish To Receive A Quote For Equipment Coverage?* Equipment coverage covers damage to equipment by fire, windstorm, theft, vandalism, etc. I wish to receive a quote for Equipment coverage. I do not wish to receive a quote for Equipment coverage. Replacement Cost Value of Equipment:* This field is required if you indicated that you wish to receive a quote for Equipment coverage. Please enter "Declined Quote" in the field below if you do not wish to receive a quote for this coverage. Description of Equipment:* Operations Information Gross Annual Receipts From Operations:* Total Number of Annual Participants* Please provide an estimated total number of participants on an annual basis. You will only count a participant one time, regardless of how many activities they participate in throughout the year. Number of Employees: Please enter 0 if none. Number of Volunteers: Please enter 0 if none. Number of Board Members: Please enter 0 if none. Number of Officers: Please enter 0 if none. Years of Experience & Type of Experience of Owners & Managers:* Are all participants required to sign waiver/release agreements?* Yes No Do you have a written risk management plan? Yes No Do you own your premises, or are you under long term lease where you are responsible for what happens 24/7?* Yes No If yes, how many acres for outdoor fields or sq feet area for indoor facilities?* Please select the option(s) below that describe your operation(s):* Select as many as apply Teams & Leagues (all sports, boy scout group, girl scout group, 4H, band, etc.) Camp/Clinic For Sports or Non Sports Tournaments/Competitions/Events (ex: baseball tournament, marathon, triathlon, cycling, walkathon, adventure race, fishing, snow skiing, snow boarding, body building, canoe/kayak, etc.) Mixed Martial Arts/Boxing Competitions Non Sports Special Events (ex: concerts, festivals, fairs, etc.) Sports/Activity Facilities (ex: sports facilities and complexes, baseball academies, batting cages, racket clubs, swim clubs, roller rinks, ice rinks, golf range, bowling centers, etc.) Amusement Facilities (ex: fun centers, go karts, rides, inflatables, mini golf, rock climbing, water park, video arcade, vending and amusement machines, haunted houses, etc.) Laser Tag/Paintball Fields/Corn Maze Martial Arts Schools And Studios Dance Schools And Studios Gymnastics Schools And Studios Fitness Classes Sports Instruction Organizations/Schools (ex: baseball, soccer, swimming, horseback riding, golf, surfing, etc.) Music Schools And Groups Productions Booster Clubs Carriage Rides Other-Please Describe Please Describe Operations* Number of Participants In Teams/Leagues Sports (Please List)* # of Adult Participants* # of Youth Participants* Camp/Clinic Information Number of Annual Participants:* Sports or Activity Description:* Youth or Adult?* Youth Adult Tentative Schedule of Event Dates:* Number of day campers: (1 day policy term)* If none, enter 0. Number of day campers: (2 day policy term)* If none, enter 0. Number of day campers: (3 day policy term)* If none, enter 0. Number of day campers: (4+ day policy term)* If none, enter 0. Number of overnight campers:* If none, enter 0. Number of coaches:* If none, enter 0. Please enter start & end dates, including the number of teams or participants per event. Tournament, Competition, or Event Tentative Schedule Please enter start & end dates, including the number of teams or participants per event. Sport* Start Date* End Date* #Teams/Participants* Youth/Adult* YouthAdult Sport: YouthAdult YouthAdult YouthAdult YouthAdult YouthAdult YouthAdult Non-Sport Event Tentative Schedule Please enter start & end dates, including the number of teams or participants and spectators per event. Activity* Start Date* End Date* # Adult Participants* # Youth Participants* # Spectators* Sports & Activities Facility Information Please enter start & end dates, including the number of teams or participants and spectators per event. Sports & Activities Description* Average Number Participants Per Day:* Number Days of Operation Per Year:* Please Explain Any Water Exposure:* Number of Travel Teams You Sponsor:* Enter 0 if none. Number of Visiting Tournament Teams For Tournaments You Host:* Enter 0 if none. Martial Arts Schools & Studios Information Number of Students in Busiest Month of Year:* Please provide a detailed description of your discipline, and comment about sparring, tournaments, and whether or not you conduct other activities such as birthday parties:* Dance Schools & Studios Information Please provide a detailed description of the type(s) of dance and your operation:* Number of Students in Busiest Month of Year:* Number of Instructors:* Information About Fitness Classes Please provide a detailed description of the type(s) of fitness activities:* Number of Students in Busiest Month of Year:* Number of Instructors:* Amusement Facilities Information Please provide a detailed description of operation, including all types of activities, attractions, rides, and games.* Average Number of Participants Per Day:* Number of Days of Operation Per Year:* Please explain any water exposure:* Gymnastic School/Studio Information Please provide a detailed description of gymnastics operations, including apparatus, instructor certification, and if tournaments are hosted.* Number of Students in Busiest Month of Year:* Number of Instructors:* Sports Instruction Organization/School Information Description of Sport or Activity:* Annual Gross Sales:* Number of Instructors:* Number of Participants In Busiest Month of the Year:* Number of Days of Operation Per Year:* Mixed Martial Arts/Boxing Competition Information & Tentative Schedule Please provide a detailed description of operations, including any state requirements for insurance:* Event Date* # of Fights* Lasertag/Paintball/Corn Maze Information Description of Operations:* Description of Layout:* # of Average Participants Per Day:* # of Days Per Year of Operations:* Music Operations Information # of Youth Students:* # of Adult Students:* Please provide a detailed explanation of operations, including type of music, location of practice and performance facilities, etc.* Booster Clubs Booster Club-Activities* What types of activities will your booster club be doing during the year? Productions Schedule & Information Production Description:* Start Date:* End Date:* Acknowledgements & Signature Fraud Warning Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement or incomplete information is guilty of insurance fraud. Applicant's Acknowledgement Below signed applicant declares that to the best of his knowledge and belief, all statements in this application are true and complete. It is understood that the application will become part of any policy as issued and that the statements provided were relied upon in the underwriting process. To sign the application, complete full name below: Applicant's Full Name:* What is the email address that is to be used for all correspondence for this policy?* Note: If you are an insurance agent and wish to receive correspondence for your insured, you must enter your email, otherwise, all information will go to the insured directly. Insurance Agent Information (If applicable) Are you a licensed insurance agent requesting a quote for your customer?* Yes No Agent Name* First Last Agency Name* Agent Email* Agent Phone* Agency Mailing Address* Where we will send renewal. Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this the first policy you have written with Sadler & Company in the last 12 months?* If yes, please print and complete the Broker application and submit. http://www.sadlersports.com/wp-content/uploads/BROKER-APP.pdf You may still quote and bind coverage, however, commissions cannot be released until this information is received. Yes No New or Renewal New Customer or Renewing Expiring Policy?* I am a new customer with Sadler Sports & Recreation I am renewing an expiring policy How Did You Hear About Sadler Sports & Recreation Insurance? Referral from a Friend Post card from Sadler Email Blast from Sadler Google Search Engine Yahoo Search Engine Other Search Engine Social Media (Facebook, Twitter, Google+, etc.) Ad showing while searching the internet What do you feel was the most effective form of communication that we used in order to inform you of your pending/expired renewal?* Formal Letter Email Post Card
