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:

From:

To:

Has Your Coverage Ever Been Canceled or Non-Renewed:

YesNo

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?

YesNo

Total sq. Footage of Off-Premises Office:

Any Other Insured Locations:

YesNo

Date of Last Board of Health Inspection:

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

YesNo

If Yes, explain:

If Not, explain security / up keep for premises:

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.):

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

YesNo

If Yes, what type:

If No, explain:

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

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):

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]

YesNo

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

YesNo

If Yes, please specify:

YesNo

YesNo

Do any activities take place off the campground premises?

YesNo

If Yes, please explain, including explanation of transportation:

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:

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::

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?

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

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

What kind of animals?

Are all animals properly vaccinated?

YesNo

Is there a hand washing station?

YesNo

If No, explain:

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: