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.):

    -----------------------------------------------------

    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

    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: