Business Name of Campground (as will appear on policy):
Doing Business As:
In Season Phone:
Off Season Phone:
Campground Web Site
Name of Agency / Brokerage:
If Other explain:
# of Years in Business:
# of Years under Present Management:
Location Where Organization is Headquartered/Chartered:
Member of a Recognized Camping Organization:
If Yes, Name of Organization:
Has Your Coverage Ever Been Canceled or Non-Renewed:
If So, Why:
Please Describe Any Prior Losses Over $5,000:
Prior Carrier Information:
Location of Campground:
Location of Off-Premises Office:
Is Off-Premises Office Located in a Commercial Building or Residence?
Total sq. Footage of Off-Premises Office:
Any Other Insured Locations:
List All Other Operations of the Named Insured, That Are Not a Part of the Campground Operations: (ie. family fun center, country club/golf course, driving range (golf), restaurant, paintball course, outfitter/guide (saddle animals or whitewater rafting), etc.)
Do you obtain a certificate of insurance from subcontractors, naming your organization as an additional insured on their insurance policy?
Date of Last Board of Health Inspection:
Do employees, management, or caretakers, etc. live on premises year round?
If Yes, explain:
If Not, explain security / up keep for premises:
How many cabins or dwellings are occupied year round?
Are all permanent structures at the insured premises owned by the named insured?
If No, please specify:
Do you have volunteers?
If Yes, for what position(s)?
Is there a training program for employees?
Is there a written Risk Management program?
Is there an emergency procedure program for the campground?
If Yes, describe?
Is there a medical log documenting illnesses, injuries, and/or treatments for campers?
Are pets allowed?
If Yes, describe rules and enforcement practices:
Are any firearms / ammunition stored or kept on site?
If Yes, please describe:
Describe cooking facilities (ie. deepfryers, grills, ovens, etc.):
Is there an Ansul or similar automatic fire protection system over all cooking surfaces?
If Yes, what type:
If No, explain:
Is there a fire station (paid or volunteer) within a 5 mile radius?
Are there fire hydrants on or near premises?
Do all sleeping rooms have smoke detectors?
Are any buildings sprinklered?
If so, which ones:
List any playground equipment and its condition:
Is the ground covered with an appropriate surface / fall zone material?
Is there an on-site sewage treatment facility?
How frequently is the tank emptied?
Where / how is sewage disposed?
How often is trash disposed of?
Is liquor sold for consumption?
Are the proper liquor licenses obtained/displayed?
Is training for servers/sellers of liquor provided?
If yes, what type:
Is liquor liability insurance requested?
Is LPG sold?
Capacity of tanks:
Are they fenced?
Who does the filling of the tanks?
What training has this person had?
Are tanks weighed after filling?
Are tanks checked for leaks after filling?
Is Certificate of Insurance from supplier on file?
Is gasoline sold?
Proper safety signs posted?
Campsites (Number of Sites):
LP Gas Sales / Servicing $ Value:
Grocery / Convenience Stores $ Value:
Cabin Rentals $ Value:
Hotels / Motels $ Value:
Restaurant $ Value:
Miniature Golf $ Value:
Gasoline Sales # of Gallons:
Arcade (including video) $ Value:
Boat Rental (LESS than 15 HP, Canoes, Kayaks, Paddle Boats, Row Boats) $ Value:
Boat Rental (MORE than 15 HP, Pontoon Boats, Ski Boats, Personal Watercraft):
Amusement Rides $ Value:
# of Rides (Kiddie Only)
ATV's / Dirt Bikes $ Value:
# of ATV's / Dirt Bikes:
Batting Cages $ Value:
# of Batting Cage Participants:
# of Golf Courses: [Supplemental Form Required]
# of Golf Carts (for Rent):
# Go Kart Tracks: [Supplemental Form Required]
# of Go Karts:
Adventure Program $ Value:
Bicycling $ Value:
Back Packing $ Value:
Caving $ Value:
Cross Country Skiing $ Value:
Driving Range (Golf) $ Value:
Fireworks # of Shows: [Supplemental Form Required]
Gymnastics # of Elements:
# of Hayrides:
# of Miniature Golf Courses:
Mountain Boarding # of Participants:
Paintball # of Fields: [Supplemental Form Required]
Petting Zoo # of Admissions:
Rafting(Class I-III) # of Boats:
# of Rifle Ranges:
# of Rock Climbing / Rappelling Participants:
# of Rope Courses / Climbing Walls:
# of Saddle Animals:
# of Sauna / Hot Tubs:
# of Skating Rinks (In-Line, Roller, Ice)
# Skateboarding Ramps / Jumps:
# of Skin / Scuba Diving:
# of Trampolines: [Supplemental Form Required]
# of Bungee Trampolines:
# of Tubing Participants:
# of Waterskiing Boats:
# of Water Trampolines (Blog, Iceberg etc.): [Supplemental Form Required]
Alpine Skiing: [Refer]
Whitewater Canoeing / Rafting: [Refer]
Does camp have a safety plan for all activities listed above? (If yes please attach below) (If no please contact Warren for a complimentary safety plan)
Does camp contract with others for program services for any of these activities?
If Yes, please specify:
Any certificates of insurance provided? (If yes please attach below)
Are any contracts signed with these groups? (If yes please attach below)
Do any activities take place off the campground premises?
If Yes, please explain, including explanation of transportation:
Total number of pools:
Is it open to members of the public?
Maximum depth of swimming area:
Is it fenced?
Are depth markings clearly visible in and around the pool?
Number of diving boards:
Depth of water at diving board entry:
Is a lifeguard provided?
If Yes, ratio of swimmers to lifeguards::
Are lifeguards certified?
If Yes, by whom::
Are rules posted at the pool area?
Any nighttime swimming allowed?
If Yes, is pool lighted::
Does your pool(s) meet the requirements of the Title XIV of public Law 110-140, known as the "Virginia Graeme Baker Pool and Spa Safety Act" as enacted on 12-18-08?
If No, explain:
Total number of lakes, ponds, or rivers:
Is swim area roped off?
Is signage posted clearly stating the depth of water and the rules for the lake / pond?
Rescue vehicle available?
If Yes, describe lighting::
If your camp provides any of the follow activities, please list the number of boats in each category below:
Personal Watercraft: (Jet Skis, Waverunners, etc.)
Motorboats under 76 HP:
Motorboats over 76 HP:
Are any boats over 21' in length?
Explain uses for powered boats and personal watercraft:
Are watercraft rented or provided by you to customers?
Is operation supervised?
Are all boats accounted for at all times?
Type, age and length of boats:
Any boats rented with motors?
Type and size of motors:
Maintenance procedures for boats and motors:
Condition of dock:
Life jackets provided?
Renters required to wear?
Boats rented to persons under 21 years of age?
Boats allowed to stay out after sunset?
Number of persons allowed in each boat:
Are renters required to sign waiver form?
Is there a marina exposure?
Are boats and motors repaired for others?
Number owned or leased:
Used at outside stable:
If subcontracted, are certificates of insurance naming camp as additional insured required?
Are limits of $1,000,000 required?
Are waivers signed by all riders?
Are riders required to wear helmets?
Are riders required to wear shoes or boots with heels?
Does an employee lead or accompany all riders?
Are riders allowed in the stable / barn area without supervision?
What kind of animals?
Are all animals properly vaccinated?
Is there a hand washing station?
Number of waterslides over 15 feet in height:
Are there attendants at the top and bottom of the slide(s) to monitor and space participants?
What is the height of each slide:
What is the length of each slide:
Is the slide maintained by a qualified maintenance person?
Is head first sliding allowed?
Are there signs posted to instruct patrons on proper behavior and riding techniques?
If Yes, where:
Scirocco Group InsuranceP: 201 727-0070 | firstname.lastname@example.org
777 Terrace Ave Suite 309 Hasbrouck Heights, NJ 07604
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