National Provider of Sports & Entertainment Insurance


13100 Shire Lane    Fort Myers, FL    33912

 (888) 288-1829 tel (630) 393-5666 fax



Sports and Recreation Facility Request for Quotation

Please complete the following information.  Once this request is received, a quotation will be sent within one business day.  As sports and recreation activities vary, some questions may not be applicable.  Please indicate "N/A" where necessary.

 * = required field

Organization Name *  
Legal Name *  
Contact Name *  


   Fax 999-999-9999

Facility Address*  
City*    State*     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*


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  



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 $


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











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    



Number of Employees         Full-time:      Part-time:




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:




The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this proposal and declares all statements set for herein are true, complete, and accurate.  The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer.


The undersigned acknowledges and agrees that the submission and the insurer's receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage.


It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies.


Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information on an application for insurance may be guilty of a crime, and may be subject to civil fines and criminal penalties. 


I certify that the above information is true and coverage is not applicable until accepted by DHC Insurance, L.L.C.


Authorized Electronic Signature*:  




DHC is a USA company and can not provide coverage outside of the USA.

Copyright © 2010-2017.  DHC Insurance, LLC.  All Rights Reserved.

13100 Shire Lane   |   Fort Myers, FL   |   33912   |  (888) 288-1829 tel   (630) 393-5666 fax

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