Amateur Sports Quotation  
Please complete the following application. Once the application is                   received, a quotation will be sent within one business day.  As sports activities vary, some questions may not be applicable.  Please indicate N/A where necessary. 
GENERAL INFORMATION  
 
 1. Organization Name: ________________________________________________________  
  
     Legal Name:  ________________________________________________________  
  
                                               Coverage Term __________ through __________  
  
2. Facility Address: ________________________________________________________  
    (Street)  (City, State, Zip)  
   
    Mailing Address(if different):       _______________________________________________  
     (Street)  (City, State, Zip)  
   
3. Contact Person:           ________________________________________________________  
  
4. Telephone Number:    (______) ____________        Fax Number:       (____) ____________  
 
5. Web site address:         ______________________   Date of Formation:     ______________  
 
6. Person responsible for general operation of activities:         ______________________  
  
    Years of experience and type of experience:            _________________________________  
  
7. How do you wish to receive your quotation?   Via Fax       (_____) ______________  
                                                                              Via E-mail  _____________________  
                                                                               Via Mail    _____________________ 
  
INSURANCE INFORMATION  
  
8. Current Policy Expiration Date:  ____________________________________________   
 
    Current Insurance Co:  __________________________________________________  
  
    Current Expiring Premium:  __________________________________________________  
  
9.  Has any insurer ever canceled or refused coverage?       Yes  No  
If yes, please explain:   __________________________________________________ 

10. Please mark the boxes for those sports that apply.  
   
 SPORT    No. of Adults  No. of Youth 
  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   ___________  ___________  
  
  Other__________   ___________  ___________  

 COVERAGES AND LIMITS  
        Limit 
  
11. Commercial General Liability  $______________________  
 General Aggregate    $______________________  
 Participant Legal Liability   $______________________  
 Products & Completed Operations (aggregate) $ ____________________  
 Personal and Advertising Injury  $______________________  
  
12. Other coverage needs: __________________________________________________________  
 ____________________________________________________________________________  
 ____________________________________________________________________________  
 ____________________________________________________________________________  
 ____________________________________________________________________________  
  
UNDERWRITING  
  
13. Total Annual Gross Receipts: $___________ Admissions: $___________  
     Concessions:   $___________ Retail:  $___________  
     Fees:    $___________  
   
14. Do you own or rent your facility/playing field?  Own   Rent  
 If rented, please provide a copy of the rental agreement from the building or park owner.  
  
15. Do you rent your facility/playing field to any other commercial operations (e.g. pro shop, sports organization, concessionaires, etc)?  
  Yes  No If yes, please explain_______________________________________________  
    _______________________________________________________________  
  
6. Square Footage of Facility/Playing Field: _________________  
1  
7. Number of employees: _________ Full-time  __________ Part-time  
1  
18. Is the facility/playing field rented for uses other than league games (birthday parties, banquets, etc.)?   Yes   No  
If yes, please provide a copy of the facility/playing field use (rental) agreement.  

 
19. Are there any amusement rides, air inflatable structures, rock climbing walls, etc.  
 on premises or brought on premises temporarily?  Yes   No  
 If yes, please describe:  _________________________________________________________  
 ____________________________________________________________________________  
 ____________________________________________________________________________  
____________________________________________________________________________  
   
20. Please describe medical and first aid facilities provided for competitors.   _________________  
 ____________________________________________________________________________  
____________________________________________________________________________  
   
21. Does your facility subcontract out any of the following operations?   
  Janitorial  Concessions        Security       Facility/Field Maintenance  
 If so, are certificates of insurance naming the facility as an additional insured obtained?  
 Yes    No  
  
22. Is there a system in place for obtaining certificates of insurance where applicable?  
  Yes   No  
 If yes, who reviews certificates on behalf of named insured?  __________________________  
 What is the minimum limit of general liability coverage requested from each   
subcontractor?  _______________________________________________________________  
   
23. Are childcare services provided?  Yes   No  
 If yes, do you do background checks on individuals providing child care services?   
  Yes   No  
 Please explain the services offered and the procedures in place to protect the   
 children while in your care.  _____________________________________________________  
 ____________________________________________________________________________  
  
24. Do you have cooking surfaces on site?  Yes   No  
 If yes, are cooking surfaces property protected from fire exposures?     
  Yes   No If yes, please explain   ________________________________________  
 ____________________________________________________________________________  
  
25. Is named insured involved in the sale or distribution of any products?  
  Yes   No  
 If yes, please explain:   _________________________________________________________  
 ____________________________________________________________________________  
  
26. Are there any special events planned at your facility/playing field during the coverage term   
 (e.g. festivals, large tournaments, etc)?  
  Yes   No Please explain   _____________________________________________  
 Estimated spectators for these events? _____________________________________________  
  
GENERAL QUESTIONS  
a.  Yes  No Are rules posted conspicuously and enforced at all times?  
b.  Yes  No Are participants required to wear safety equipment during play?  
c.  Yes  No Are participants required to sign a Waiver & Release of Liability?  
   Please provide a copy.  
d.  Yes  No Are copies of the Waiver & Release of Liability kept on file? How   
   long? _______________________________________________  
e.  Yes  No Are the referees or coaches employees of your organization?  
f.  Yes  No Are parking lots well lit and patrolled?  
g.  Yes  No Are facility/playing field inspections and maintenance performed?  
h.  Yes  No Is a log kept of inspections and maintenance performed?  
i.  Yes  No Are written emergency procedures in place? (attach copy)  
j.  Yes  No Does the facility rent or repair sports equipment?  
k.  Yes  No Is the facility locked so that patrons cannot use it when closed?   
   primary concern is outdoor activities  
l.  Yes  No Are there construction operations on site? If yes, is the work   
   subcontracted to a third party with additional insured certificates   
   provided?  ___________________________________________  

 27. Please also provide (quote will not be released until all of these materials are  
 received and reviewed):  
  Loss runs for the past three years (if applicable)  
  Emergency procedures  
  Lease agreement if your facility/playing field is not owned  
  Sample waiver and release of liability  
  
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 in 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 Athos Insurance Services, LLC  
  
Signature of Applicant  ______________________________________________________________  
  
Date  _____________________________________________________________________________________  

  
  
Katherine M. Wong, CPCU, CLCS
Athos Insurance Services, LLC
P.O. Box 61102
Pasadena, CA 91116
Phone: 626-716-9800
Mobile (text): 626-379-6280
Fax: 626-701-5047
Email: Kat@athosinsurance.com
Lic: 0H94681