Campground Insurance Application

General Information




My Email:

My Name:




Business Name of Campground
(as will appear on policy):




Doing Business As:




Mailing Address:

City:




State:

Zip:




Contact Person:

FEIN#:




Person is:

OwnerPromoterAgentOther




If Other:




In Season Phone:

Off Season Phone:




Fax:




Campground Web Site




Name of Agency / Brokerage:




Contact Person:

E-Mail Address:




Mailing Address:

City:




State:

Zip:




Phone:

Fax:





Insured is:

CorporationPartnershipJoint VentureFor Profit501 3C Non ProfitOther





If Other explain:




# of Years in Business:

# of Years under Present Management:




Location Where
Organization is Headquartered/Chartered:





Member of a Recognized Camping Organization:

YesNo

If Yes, Name of Organization:




Policy Period Requested:


From:

To:




Has Your Coverage Ever Been Canceled or
Non-Renewed:

YesNo

If So, Why:





Please Describe Any Prior Losses Over $5,000:











YEAR

PREVIOUS AGENT

COMPANY

LIABILITY LIMITS

PREMIUM

LOSSES


Prior Carrier Information:












Coverage Information




ADDITIONAL INSUREDS

RELATIONSHIP

ADDRESS












Location of Campground:




Location of Off-Premises Office:




Is Off-Premises Office Located in a Commercial Building or Residence?

YesNo





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?




YesNo




Date of Last Board of Health Inspection:



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Do employees, management, or caretakers, etc. live on premises year round?

YesNo






If Yes, explain:

If Not, explain security / up keep for premises:


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How many cabins or dwellings are occupied year round?




By Whom?




Are all permanent structures at the insured premises owned by the named insured?

YesNo

If No, please specify:





Do you have volunteers?

YesNo

If Yes, for what position(s)?





Is there a training program for employees?

YesNo

Is there a written Risk Management program?

YesNo





Is there an emergency procedure program for the campground?

YesNo

If Yes, describe?





Is there a medical log documenting illnesses, injuries, and/or treatments for campers?

YesNo





Are pets allowed?

YesNo

If Yes, describe rules and enforcement practices:





Are any firearms / ammunition stored or kept on site?

YesNo

If Yes, please describe:





Describe cooking facilities (ie. deepfryers, grills, ovens, etc.):



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Is there an Ansul or similar automatic fire protection system over all cooking surfaces?

YesNo





If Yes, what type:

If No, explain:


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Is there a fire station (paid or volunteer) within a 5 mile radius?

YesNo

Are there fire hydrants on or near premises?

YesNo





Do all sleeping rooms have smoke detectors?

YesNo





Are any buildings sprinklered?

YesNo

If so, which ones:





List any playground equipment and its condition:












Is the ground covered with an appropriate surface / fall zone material?

YesNo





Is there an on-site sewage treatment facility?

YesNo

If yes:

Campers OnlyGeneral Public








How frequently is the tank emptied?




Where / how is sewage disposed?

City / County Sewer SystemDrive away service contractedPumped into pond, cesspool, waterway, or lagoon








How often is trash disposed of?





Is liquor sold for consumption?

YesNo

If yes:

By the DrinkFor Carry-Out





Are the proper liquor licenses obtained/displayed?

YesNo





Is training for servers/sellers of liquor provided?

YesNo





If yes, what type:




Is liquor liability insurance requested?

YesNo





Is LPG sold?

YesNo

Capacity of tanks:





Are they fenced?

YesNo

Fence height:





Who does the filling of the tanks?




What training has this person had?




Are tanks weighed after filling?

YesNo

Are tanks checked for leaks after filling?

YesNo





Is Certificate of Insurance from supplier on file?

YesNo





Is gasoline sold?

YesNo

Self-service:

YesNo





Proper safety signs posted?

YesNo





Exposures




Campsites (Number of Sites):

$ Value:




LP Gas Sales / Servicing $ Value:

Grocery / Convenience Stores $ Value:




Cabin Rentals $ Value:

Hotels / Motels $ Value:




Restaurant $ Value:

Miniature Golf $ Value:




Gasoline Sales # of Gallons:

Self ServiceFull ServiceRepair Service








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):




Activities




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]

Archery:

YesNo





Alpine Skiing:
[Refer]

YesNo

Whitewater Canoeing / Rafting:
[Refer]

YesNo





Other:
[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)









YesNo





Does camp contract with others for program services for any of these activities?

YesNo

If Yes, please specify:





Any certificates of insurance provided?
(If yes please attach below)








YesNo




Are any contracts signed with these groups?
(If yes please attach below)








YesNo





Do any activities take place off the campground premises?

YesNo

If Yes, please explain, including explanation of transportation:










If Campground Utilizes A Pool:




Total number of pools:

Is it open to members of the public?

YesNo




Maximum depth of swimming area:




Is it fenced?

YesNo

Height:





Are depth markings clearly visible in and around the pool?

YesNo





Number of diving boards:

Height:




Depth of water at diving board entry:

YesNo





Is a lifeguard provided?

YesNo

If Yes, ratio of swimmers to lifeguards::





Are lifeguards certified?

YesNo

If Yes, by whom::





Are rules posted at the pool area?

YesNo





Any nighttime swimming allowed?

YesNo

If Yes, is pool lighted::

YesNo





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?

YesNo

If No, explain:








If Campground Utilizes A Lake, Pond, Or River:




Total number of lakes, ponds, or rivers:

Is it open to members of the public?

YesNo




Maximum depth of swimming area:




Is swim area roped off?

YesNo

Is signage posted clearly stating the depth of water and the rules for the lake / pond?

YesNo





Number of diving boards:

Height:




Depth of water at diving board entry:





Is a lifeguard provided?

YesNo

If Yes, ratio of swimmers to lifeguards::





Are lifeguards certified?

YesNo

If Yes, by whom::





Rescue vehicle available?

YesNo





Any nighttime swimming allowed?

YesNo

If Yes, describe lighting::





Tubing, Rafting, Canoeing, Kayaking,

Sailing or Boating:






If your camp provides any of the follow activities,
please list the number of boats in each category below:


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Canoes:

Kayaks:




Rowboats:

Paddleboats:




Sailboats:

Personal Watercraft:
(Jet Skis, Waverunners, etc.)




Motorboats under 76 HP:

Motorboats over 76 HP:




Are any boats over 21' in length?


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Explain uses for powered boats and personal watercraft:




Are watercraft rented or provided by you to customers?

YesNo

Is operation supervised?

YesNo





Are all boats accounted for at all times?

YesNo





Type, age and length of boats:




Any boats rented with motors?

YesNo





Type and size of motors:




Maintenance procedures for boats and motors:




Condition of dock:




Life jackets provided?

YesNo

Renters required to wear?

YesNo





Boats rented to persons under 21 years of age?

YesNo

Boats allowed to stay out after sunset?

YesNo





Number of persons allowed in each boat:

Are renters required to sign waiver form?

YesNo





Is there a marina exposure?

YesNo

Are boats and motors repaired for others?

YesNo





Saddle Animals




Number owned or leased:

Used at outside stable:




If subcontracted, are certificates of insurance naming camp as additional insured required?

YesNo





Are limits of $1,000,000 required?

YesNo

If No, explain:





Are waivers signed by all riders?

YesNo

Are riders required to wear helmets?

YesNo





Are riders required to wear shoes or boots with heels?

YesNo

Does an employee lead or accompany all riders?

YesNo





Are riders allowed in the stable / barn area without supervision?

YesNo





Petting Zoo




What kind of animals?

Are all animals properly vaccinated?

YesNo





Is there a hand washing station?

YesNo

If No, explain:





Waterslide




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?

YesNo





What is the height of each slide:

What is the length of each slide:












Is the slide maintained by a qualified maintenance person?

YesNo

Is head first sliding allowed?

YesNo





Are there signs posted to instruct patrons on proper behavior and riding techniques?

YesNo

If Yes, where: