* = required field

Organization Name *
Legal Name *
Contact Name *
Email*	Fax 999-999-9999
Facility Address*
City*	State*   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip Code *
Phone*	999-999-9999
How do you wish to receive your Quotation?*	Email  Fax   Mail
Coverage Term Requested*	through
Web Address
Person Responsible for General Operation of Activities*
Years & Type of Experience*

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Insurance Information
Current Policy Expiration Date
Current Insurance Company
Current Expiring Premium
Has any insurer ever canceled or refused coverage?	Yes   No
If Yes, Explain
Sports or Recreational Activities (check all that apply):
Aerobics Badminton Baseball Basketball Boxing Cheerleading Cross Country Skiing Field Hockey Flag Football Floor Hockey Golf Ice Hockey Lacrosse Martial Arts Roller Hockey Rugby Soccer Softball Swimming T-Ball Tackle Football Tennis Track Volleyball Weightlifting Wrestling Ultimate Frisbee           Airsoft Batting Cages Bowling Lanes Exercise Machines Firearm Shooting Go Carts Laser Tag Miniature Golf Motocross Paintball Skateboard Ramps           Other
Insurance Limits Requested (leave blank for Minimum Limits):

Commercial General Liability
	Single Limit Per Occurrence	$
	General Aggregate	$
	Personal & Advertising Injury	$
	Fire Damage	$
	Medical Expense	$
Participant / Staff Accident Insurance
	Maximum Medical Expense Benefit	$
	Accidental Death Benefit	$
	Accidental Dismemberment Benefit	$
Hired and Non-Owned Automobile Liability
	Single Limit Per Occurrence	$
	General Aggregate	$
Inland Marine (Equipment Coverage)
	Value of Insured Equipment	$

Underwriting

Total Annual Gross Receipts (If this is a new facility, please provide an annual estimate):
	Admissions	$
	Concessions	$
	Retail	$

 

Own or Rent Do you own or rent your facility/playing field?  Own  Rent                   If Rent, please fax or email a copy of the rental agreement from the building or park owner.

Do you rent your facility/playing field to any other commercial operations (e.g. pro shop, sports organizations, concessionaires, etc)? Yes   No   Square Footage Square Footage of Facility/Playing Field       Employees Number of Employees         Full-time:      Part-time:   Subcontracting   Does your facility subcontract out any of the following operations? Janitorial   Concessions   Security   Facility / Field Maintenance   Childcare Services Are childcare services provided?  Yes   No                If Yes, please explain the services offered and the procedures in place to protect the children while in your care.   Cooking Surfaces Do you have cooking surfaces on site? Yes   No     Special Events Planned Are there any special events planned at your facility/playing field during the coverage term?   Yes  No     (e.g. festivals, large tournaments, etc.)   Event:    Number of Estimated Spectators:    Event:    Number of Estimated Spectators:    Event:    Number of Estimated Spectators:        General Questions     Are rules posted conspicuously and enforced at all times? Yes   No   Are participants required to wear safety equipment during play? Yes   No   Are participants required to sign a Waiver & Release of Liability? Yes   No   Are copies of Waiver & Release of Liability kept on file? Yes   No   Are the referees or coaches employees of your organization? Yes   No   Are parking lots well lit and patrolled? Yes   No   Are facility/playing field inspections and maintenance performed? Yes   No   Is a log maintained of inspections and maintenance performed? Yes   No   Are written emergency procedures in place? Yes   No   Does the facility rent or repair sports equipment? Yes   No   Is the facility locked so that patrons cannot use it when closed? Yes   No   Are there construction operations on site? Yes   No   Does the facility have a fire alarm? Yes   No   Does the facility have automatic fire sprinklers? Yes   No   Does the facility have and Automated External Defibrillator? Yes   No   Does the facility contain fire extinguishers? Yes   No   Are all exits clearly marked? Yes   No   After you submit this Request, please fax or email the following items: Prior insurance experience reports for the past 3 years Emergency procedures or other documentations Lease agreement if your facility/playing field is not owned Sample Waiver and Release of Liability Forms Fax:   (630)393-5666          Email:  info@dhcins.com