Matterhorn Consolidated Sports Application

Matterhorn Consolidated Sports Application
Please select the coverage(s) that you would like to include in your insurance application
Select all applicable insurance coverages for sports below*

AccidentGeneral Liability & SA&MDirectors & OfficersCrime / CyberProperty
Broker Information
Broker/Agency Name*
Contact Person*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Applicant Information
Business Name*
Contact Person*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Website*
Type of Group*

Teams/Clubs/LeaguesEvents/ToursAssociationNot-for-profitEmployerCamp/ClinicAcademyOther
Other*
Are you a Member of an Association?*

YesNo
Association Name*
Accident Coverage

Policy Information
Effective Date*

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Quote Need By Date

MonthDayYear
Date
Previous Insurance Carrier
Insurance for Partcipant Accident is*

MandatoryVoluntary
Description of Covered Person
Description of Covered Activities
Does coverage provide for

Participation in Covered Activities only?Travel to and from Covered Activities?Overnight exposure? If yes, enter details in Participant Information table below.Coverage outside the contiguous U.S.A. (including Alaska and Hawaii)?

Policy Term

	Year	Year	Year	Year
Year
Insurance Carrier:
AD&D Limits:
AME Limits:
Deductible:
Annual Premium:
** Total Incurred Losses:
Total # of Participants/ Membership Covered
Total # of Coaches, Officials & Volunteers

Mandatory or Voluntary?

MandatoryVoluntary
Excess or Primary?

ExcessPrimary
Have coverages ever been canceled or non-renewed during the past 5 years?

YesNo
If Yes, please provide an explanation
Please provide past 5 years’ hard copy Loss Runs and description of any individual claim or reserve

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Coverage and Limits
Accidental Death & Dismemberment

$5,000$10,000$25,000$50,000$50,000 +
AD&D Aggregate Limit
Accident Medical Expense

$1,000$5,000$10,000$25,000$50,000
Deductible

$0$50$100$250$500
Excess or Primary?

ExcessPrimary
Type of Sport*

BaseballBasketballCricketField HockeyLacrosseTennisPickleballRacquetballOther
Other*
Total Number of Coaches*
Total Estimated Number of Participants by Age
14 & Under: *
15 - 18: *
19+*
Total Estimated Number of Participants by Type
Coaches:*
Officials:*
Spectators:*
Volunteers:*
Participants:*

Sports & Activities

	Event Start Date	Event End Date	Overnight Stays	Under 5	5-14	15-18	19-64	65+	Coaches	Officials	Spectators	Volunteers
Baseball
Basketball
Cricket
Field Hockey
Lacrosse
Tennis
Pickleball
Racquetball

Percentage of Sports Played by Male*
Percentage of Sports Played by Female*
General Liability & Sexual Abuse and Molestation

Please Provide Name of Officers
President
Executive Director
Manager
Does the insured engage in any other operations under the named insured or additional insureds?

YesNo
If yes, please provide details:
Is this insurance going to extend to these groups on a blanket basis?

YesNo
If yes, please provide details:
Years this entity has been in business
Type of Sport*

BaseballBasketballCricketField HockeyLacrosseTennisPickleballRacquetballOther
Other*
Total Number of Coaches*
Total Estimated Number of Participants by Age
14 & Under: *
15 - 18: *
19+*
Total Estimated Number of Participants by Type
Coaches:*
Officials:*
Spectators:*
Volunteers:*
Participants:*

Sports & Activities

	Event Start Date	Event End Date	Overnight Stays	Under 5	5-14	15-18	19-64	65+	Coaches	Officials	Spectators	Volunteers
Baseball
Basketball
Cricket
Field Hockey
Lacrosse
Tennis
Pickleball
Racquetball

Percentage of Sports Played by Male*
Percentage of Sports Played by Female*
POLICY COVERAGE INFORMATION
General Aggregate Limit (other than products/completed operations)
Products and completed operations aggregate limit
Personal and advertising injury
Damage to premises rented to you
Medical expense
Sexual abuse & molestation
Hired & Non-Owned Auto Liability
During the past three years, has any company ever canceled, declined or refused similar?

YesNo
If yes, explain
Proposed Effective Date
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Underwriting Information
Is there a swimming pool or other bodies of water where swimming is permitted?

YesNo
Please provide details of the management experience
Does the Applicant keep a log of all incidents?

YesNo
Are staff members trained in CPR?

YesNo
Is a CPR trained staff member on duty at all times?

YesNo
Does the Applicant have stated concussion protocol and/or guidelines?

YesNo
If yes, please provide a copy.

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Any overnight stays?

YesNo
Does the named insured own or have 24 hour responsibility of a facility or field?

YesNo
Type of organization

Individual teamLeague or club (an entity organized to provide regulated competition for multiple teams participating in a specific sport)Association (an entity, usually not-for-profit, that exists to further a particular sport, to protect the public interest and the interests of the participants of that sport. A fee is typically charged to become a member and formal rules/regulations are usually required and enforced)
Are you a school sanctioned sports team or league?

YesNo
Are you a gymnastics, martial arts, cheer or dance studio?

YesNo
Are you a municipality or a park and recreation division?

YesNo
Have any of the Applicant’s directors, officers or employees been convicted of any crime within the past 10 years?

YesNo
If yes, please explain
Is there a formal athlete injury control program?

YesNo
If yes, please provide a copy of the complete program

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Months of Operation
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Do you, your organization or sanctioning/governing body have written procedures and training in place regarding the prevention and mitigation of abuse, molestation or sexual misconduct?

YesNo
If yes, do they include how to recognize the signs of abuse and molestation

YesNo
All known, alleged or suspected abuse incidents must be reported to law enforcement

YesNo
Procedures are provided or available to all paid and volunteer staff, and sanctioning

YesNo governing body members
No one-on-one situations allowed without visibility by others

YesNo
A supervision plan to monitor all participants at the facility/event site that also prevents

YesNo access to secluded areas such as closets, unsupervised rooms, etc.
A supervision plan to monitor all participants at the facility/event site that also prevents

YesNo access to secluded areas such as closets, unsupervised rooms, etc.
A policy regarding appropriate and inappropriate physical contact, verbal interaction and business activities

YesNo electronic communications with children during and outside of regularly scheduled
Have any claims, allegations, or charges of abuse, molestation, or sexual misconduct been made against you or your organization?

YesNo
Do you have written policies and procedures for the prevention of abuse and handling of allegations?

YesNo
If no, please provide a detailed explanation:
Are you aware of any occurrences that could lead to a claim?

YesNo
How is the information transmitted to employees and volunteers? i.e. employee/volunteer handbook, orientation training, formal training, etc. Are records kept or files documented on the training?

YesNo
Please describe your incident reporting procedures:
Do the employment applications ask about past accusations or convictions including sex related offenses or child abuse?

YesNo
Do the volunteer applications ask about past accusations or convictions including sex related offenses or child abuse?

YesNo
Have any claims, allegations or charges of abuse, molestation or sexual misconduct been made against you or your organization or anyone working on behalf of your organization?

YesNo
If yes, please explain
If applications include questions about convictions for physical violence or sex-related offenses, and if an applicant checks "Yes," are they rejected?

YesNo
Does you organization have any of the following exposures for minors:

Overnight travelOvernight accommodationsCampgroundsDaycarePersonal care of minors i.e. bathing, changing clothes, toiletingOther
Does the Applicant perform criminal background checks for employees?

YesNo
Does the Applicant perform criminal background checks for volunteers?

YesNo
Do you require any contractors that have care or supervision over minors in your operation to carry abuse and molestation coverage?

YesNo
If yes, please provide the required limits
Food & Bev Information
Does the applicant operate a concession stand?

YesNo
List types of foods/beverages sold
Submission check list

Company loss runs currently values for the past 3 years including current yearCopies of expiring policies including any manuscript formsDetailed list of all insureds and their descriptionsDetailed list of all insured locations and their descriptionsList & description of any ancillary activities to be coveredCopies of all event brochures you participant inCopy of adult and minor waiver and release and/or assumption of risk formsCopy of your formal athlete injury control programCopy of your procedures for screening employees and volunteersCopy of your abuse and molestation policy and procedures
Additional Info

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Directors & Officers
Describe the Organization Operations
Annual Salary/Wage Expense
Total Assets
Name of all Subsidiaries
Date of acquisition/creation of subsidiaries
Percentage of control for subsidiaries
Description of operations for each subsidiaries
Which of the following applies to the subsidiaries?

Non-profitFor-profit
Name of parent organization
Attach financial statements (if not consolidated) for each subsidiaries

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Is the Organization or any of its subsidiaries involved in or presently considering any merger, consolidation, acquisition, divestment or sale of a portion of its business or has a similar transaction been considered or completed within the last three years?

YesNo
If yes, please provide details
Does the Organization or any proposed Insured perform, or are they involved in, any of the following?

Services involving childrenCollective Bargaining or Lavor AdvocacyMental Health / Rehabilitation CounselingMedical ServicesLegal or Arbitration ServicesTeach / EducatorFinancial CounselingBroadcasting / PublishingLobbyingInsurance or Investment AdvisorFoster Care / AdoptionResearch & DevelopmentOther Professional Services
Does the Organization take any disciplinary action or recommend disciplinary action as a result of credentials certification, accreditation, licensing, peer review or standard setting activities?

YesNo
Please provide Date Organized

MonthDayYear
Date
If yes, please provide details
Does the Organization currently have Directors' & Officers' and Employment Practice Liability Insurance?

YesNo
Current Expiration Date

MonthDayYear
Date
Current Limit
Current Premium
Has any carrier cancelled or non-renewed similar coverages?

YesNo
If yes, please provide details
Provide the number of employees at the Organization:
including officers
Provide the number of employees and officers whose employment has been involuntarily terminated in the last twelve months.
Provide the number of employees and officers whose employment is expected to be involuntarily terminated over the next twelve months through layoffs, facility closings, individual involuntary employee terminations or similar circumstances.
In the last twelve months have there been any changes in the Executive Director or President position for reasons other than death, retirement at the normal retirement age or term limitations?

YesNo
If yes, please provide details
Please enter the Total Asset Value for each of the Employee Benefit Plans (referred to as the Plans) sponsored by the Organization or its Subsidiaries for which coverage is desired
Defined Contribution Plans (including 401(K), 403 (B), 7 457 Plans)
Please enter the Total Asset Value for each of the Employee Benefit Plans (referred to as the Plans) sponsored by the Organization or its Subsidiaries for which coverage is desired.
Defined Benefit Plans (including Traditional Pension Plans)
Has the Organization or any Subsidiary terminated or contemplated terminating any of the Plans within the past three years or within the next 12 months?

YesNo
If yes, please provide details
Do any of the Plans fail to comply with the "Employee Retirement Income Security Act of 1974" (ERISA) where applicable?

YesNo
If yes, please provide details
Has any Plan had, at any time during the last three years, a funding deficiency?

YesNo
If yes, please provide details
Crime / Cyber
Please attach a list of all Insureds, including Employee Benefit Plans

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Website
Policy Effective Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Employee Dishonesty
Deductible Per Occurrence $
Limit of Insurance Per Occurrence $
ERISA Theft
Deductible Per Occurrence $
Limit of Insurance Per Occurrence $
Deductible Per Occurrence $
Outside the Premises
Limit of Insurance Per Occurrence $
Computer Hacking
Limit of Insurance Per Occurrence $
Deductible Per Occurrence $
Fraudulently Induced Transfer
Limit of Insurance Per Occurrence $
Deductible Per Occurrence $
Funds Transfer Fraud
Limit of Insurance Per Occurrence $
Money Orders and Counterfeit Paper Cash
Limit of Insurance Per Occurrence $
Credit, Debit, or Charge Card Forgery
Limit of Insurance Per Occurrence $
Deductible Per Occurrence $
Claims Expense Coverage
Deductible Per Occurrence $
Coverage Amendments (Endorsements)
Is Kidnap, Ransom, and Extortion Coverage Desired? (Separate application required)

YesNo
Legal Entity

ProprietorshipPartnershipCorporationOther
Other Legal Entity
Classify your predominant business activity

ManufacturerProcessorWholesalerDistributorRetailerServicer
Other predominant business activity
Do you or any of your subsidiaries operate in any capacity differently than what is listed above?

YesNo
If yes, please provide details
Have you completed any mergers or acquisitions within the past year?

YesNo
If yes, please provide details as to the name of company acquired, date of transaction, description of operations, asset size and number of employees.
Has there been any change in ownership of management within the past three years?

YesNo
If yes, please provide an explanation
Total number of U.S. Employees
Total number of Canada Employees
Total number of Foreign Employees
Grand Total of all Employees
Total number of U.S. Locations
Total number of Canada Locations
Total number of Foreign Locations
Grand total of all Locations
Please attach Total Employee Census by department

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Do you have any losses with the last 5 years?

YesNo
Type/Description of Occurrence or Claim
Date of Claim

MonthDayYear
Date
Is this claim open or closed?
Comments/Corrective Action Taken

Gross Assets / Gross Sales / Net Income / Net Worth / Equity

	% change from prior year	Total
Annual Gross Assets
Annual Gross Sales
Net Income
Net Worth
Equity

Are your annual financial statements audited by a public accountant?

YesNo
Is the public accountant's opinion unqualified?

YesNo
Does it include all interests and locations on an annual basis?

YesNo
Have all recommendations made by the accountant been adopted?

YesNo
Are all reports sent directly by the Owner, Partners, or Directors?

YesNo
Is there an internal audit department?

YesNo
If yes, what is the headcount?
Is there a formal audit program?

YesNo
Does the auditor have the authority to check anyone and any record at any time?
Does the auditor originate entries?

YesNo
If weaknesses are discovered, does the auditor report in writing to the First Named Insured?

YesNo
Do you audit your Wire Transfer procedures?

YesNo
Are foreign locations audited at least annually?

YesNo
Are foreign locations audited by

U.S. AuditorForeign Auditor
Briefly describe the company's fraud reporting controls, such as hotline, anonymous reporting, etc., used to report allegations of fraud, either internally or externally, domestically or foreign.
Bank Accounts
Are bank accounts reconciled monthly?

YesNo
Are bank accounts reconciled by someone not authorized to deposit, withdraw or write someone checks?

YesNo
Is a countersignature of all checks required?

YesNo
Above what amount?
If no, describe the system in effect to prevent unauthorized insurance of checks
Check & Securities
Is a Positive Pay system utilized with your financial institution?

YesNo
Do all vouchers or other supporting records accompany all checks to be signed?

YesNo
Are vouchers/supporting records stamped "PAID" when checks are signed?

YesNo
Are all incoming checks scanned within the date received or stamped "For Deposit Only"?

YesNo
Are your systems designed so that no single employee can control a transaction from beginning to end (e.g. approve a voucher, request and sign a check)?

YesNo
Are securities subject to the joint control of two or more employees?

YesNo
Are securities subject to the joint control of two or more employees?

YesNo
Are all controls and procedures consistent throughout all locations including foreign locations?

YesNo
Accounts Receivable
Are at least 20% of all of the accounts receivable periodically verified by direct contact with the customers?

YesNo
Payroll
Are background checks performed on all new hires?

YesNo
Are background checks performed on all new hires?

CriminalCreditPrior EmploymentReferencesDrug Testing
Have you hired or retained persons with prior acts of dishonesty convictions?

YesNo
If yes, do you have Employees working in the State of New York?
If yes to previous question, do you weigh the factors set out in New York State Corrections Law Article 23-A in making the determination to hire or retain such persons?

YesNo
Do you maintain documentation of your New York State Corrections Law Article 23-A assessment?

YesNo
Does the audit department have a program in place to detect potential ghost employees ad is the payroll system audited annually at a minimum?

YesNo
Is payroll processed by persons other than those who distribute it to employees?

YesNo
Are all persons who are authorized to hire an/or fire employees prohibited from distributing the payroll?

YesNo
Are all persons who are authorized to hire an/or fire employees prohibited from distributing the payroll?

YesNo
Shipping & Receiving
Are all persons engaged in purchase or sales activities prohibited from taking part in shipping and receiving activities?

YesNo
Are all shipping and receiving activities reconciled to all applicable sales or purchase orders?

YesNo
Do any employee have access to the purchasing system and also the accounts payable system?

YesNo
Is all purchasing centralized out of your main office?

YesNo
Do you have a system to detect payment to fictitious suppliers?

YesNo
Are cash or credits on return purchases supervised by at least two persons?

YesNo
Supevision by Owner
Is there personal supervision on business activities on a daily basis by an Owner, Partner, or Director?

YesNo
Does the person do the following:
Deposit all cash receipts?

YesNo
Sign or countersign all checks?

YesNo
Check petty cash periodically?

YesNo
Verify periodically accounts receivable?

YesNo
Reconcile all bank accounts?

YesNo
Verify shipping and receiving activities?

YesNo
Verify shipping and receiving activities?

YesNo
Review journal entries?

YesNo
Cryptocurrency
Do you own, hold or accept as payment any form of cryptocurrencies?

YesNo
If yes, please upload a list of all cryptocurrencies and their current values

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How are these secured?

In a walletExchangeHot (connected to the internet)Cold (not connected to the internet)
Please describe the form of cold storage
Is a qualified third-party custodian responsible for holding your cryptocurrencies in cold storage?

YesNo
Please provide a detailed description of the form of hot storage and what controls are in place to avoid a loss
Do you maintain a secure log for every transaction including address, key and algorithms?

YesNo
Does this include the date of receipt and the amount transacted?

YesNo
Do you have segregation of duties for the logs and employees who handles the cryptocurrencies?

YesNo
What audit procedures are in place and how often do you do a reconciliation of the cryptocurrencies?
If you are not currently using cryptocurrencies do you anticipate using them in the current policy period?

YesNo
If yes, provide detailed information on which ones
What departments conduct wire fund transfers?
Do you maintain a fully documented procedure manual covering all wire transfer procedures?

YesNo
Are all payment instructions executed under a sequential numbering sequence?

YesNo
Is there an internal audit department which includes E.D.P. auditing?

YesNo
If there is no internal audit department, please advise how this function is fulfilled
If you utilize consultants, do you change passwords immediately after they finish their work?

YesNo
What is the total daily volume of funds transferred?
What is the largest amount one person can transfer?
Are all funds transfer functions handled by banks and/or financial institutions?

YesNo
Do you have facilities to transfer funds yourself without involving third parties?

YesNo
Are all telephone transfer instructions given to banks confirmed in writing within 24 hours?

YesNo
Is there segregation of duties so that no one employee can initiate and complete transactions without approval by others?

YesNo
Do you change employee passwords immediately upon their termination?

YesNo
Describe controls in place to prevent unauthorized use of computers by employees or others? (i.e. are computer rooms locked, maintenance ports protected, etc)
How do you detect whether an employee has exceeded their authority?
Property
Application is hereby made by
Policy Effective Period
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date

Insuring Agreement

	Limit of Insurance (Per Occurance)	Deductible (Per Occurance)
Employee Dishonesty
Employee Theft of Clients Property
ERISA Theft
Forgery or Alteration
Inside the Premises
Outside the Premises
Computer Hacking
Fraudulently Induced Transfer
Funds Transfer Fraud
Destruction of Data by Hacker
Money Orders and Counterfeit Paper Cash
Credit, Debit or Charge Card Forgery
Claims Expense Coverage

Description of your Organization
Classify your predominant business activity

ManufacturerProcessorWholesalerDistributerRetailerServicerOther
Other
Do you or any of your subsidiaries operate in any capacity differently than what is listed above?

YesNo
If yes, please provide details.
Have you completed any mergers or acquisitions within the past year?

YesNo
If yes, please provide details.
Has there been any change in ownership or management within the past three years?

YesNo
If yes, please provide details.

Classification of Employees and Locations

	Employees	Locations	Grand Total
U.S.
Canada
Foreign

Loss History

	Date of Occurence	Type/Description of Occurence or Claim	Date of Claim	Gross Loss	Claim Status
1.
2.
3.

Financial Status

	Total	% Change from prior year
Annual Gross Assets
Annual Gross Sales
Net Income
Net Worth
Equity

Audit Procedures
Are your annual financial statements audited by a public accountant?

YesNo
Is the public accountant’s opinion unqualified?

YesNo
Does it include all interests and locations on an annual basis?

YesNo
Have all recommendations made by the accountant been adopted?

YesNo
Are all reports sent directly to the Owner, Partners or Directors?

YesNo
Is there an internal audit department?

YesNo
Does the internal audit department conduct an audit of all interests

AnnuallySurprise Basis
Is there a formal audit program?

YesNo
Does the auditor have the authority to check anyone and any record at any time?

YesNo
Does the auditor originate entries?

YesNo
If weaknesses are discovered, does the auditor report in writing to the First Named Insured?

YesNo
Do you audit your Wire Transfer procedures?

YesNo
Are foreign locations audited at least annually?

YesNo
Are foreign locations audited by

U.S. AuditorForeign Auditor
Internal Controls
Are all persons engaged in purchase or sales activities prohibited from taking part in shipping and receiving activities?

YesNo
Are all shipping and receiving activities reconciled to all applicable sale or purchase orders?

YesNo
Are all controls and procedures consistent throughout all locations including foreign locations?

YesNo
Do you own, hold or accept as payment any form of cryptocurrencies?

YesNo
How are these secured?

In a walletExchangeHot (connected to the internet)Cold (not connected to the internet)
Describe controls in place to prevent unauthorized use of computers by employees or others?

YesNo
Are background checks performed on all vendors in order to determine ownership and financial capability prior to doing business with them?

YesNo
Is an authorized master vendor list utilized and updated for all annual purchases, with competitive bidding required over stated amounts?

YesNo
Are background checks performed on all vendors in order to determine ownership and financial capability prior to doing business with them?

YesNo
Are the assets of the Plan(s) administered by an independent third party?

YesNo
Has any similar insurance been declined or canceled during the past three years?

YesNo

Prior insurance to be superseded

	Form of Insurance	Effective Date	Expiration Date	Limit of Insurance	Name of Insurance Company
1.
2.

Provide the maximum amount held at, or transported from, for all locations.

Cash: $ blanks Check: $blankNegotiable Securities: $
What type of alarm(s) do you have at each of your premises?

Hold-up AlarmPremises AlarmSafe AlarmLocal GongCentral Station AlarmPolice Connected Alarm
Do you store all negotiable securities and/or cash in a secured safe/vault?

YesNo
Do you buy or sell goods via the internet?

YesNo
Do you have a firewall?

YesNo
Do you have an intrusion detection system that identifies unauthorized access?

YesNo
Has your computer system ever been invaded by a hacker or virus?

YesNo
If yes, when and what controls have been implemented to prevent further incidences?
APPLICANT ACCEPTANCE/SIGNATURE
Full Name

First NameLast Name
Title
Date*

MonthDayYear
Date
By signing or electronically accepting this Request Form, I agree to conduct electronic commerce and to accept anelectronic insurance policy and other documents issued by Everest. I acknowledge that I may request a written policy.*

Clear
Should be Empty:

Matterhorn Consolidated Sports Application

Please select the coverage(s) that you would like to include in your insurance application

Broker Information

General Applicant Information

Accident Coverage

Coverage and Limits

Total Estimated Number of Participants by Age

Total Estimated Number of Participants by Type

General Liability & Sexual Abuse and Molestation

Total Estimated Number of Participants by Age

Total Estimated Number of Participants by Type

POLICY COVERAGE INFORMATION

Proposed Effective Date

Underwriting Information

Please provide details of the management experience

Months of Operation

Food & Bev Information

Directors & Officers

Crime / Cyber

Employee Dishonesty

ERISA Theft

Outside the Premises

Computer Hacking

Fraudulently Induced Transfer

Funds Transfer Fraud

Money Orders and Counterfeit Paper Cash

Credit, Debit, or Charge Card Forgery

Claims Expense Coverage

Grand Total of all Employees

Bank Accounts

Check & Securities

Accounts Receivable

Payroll

Shipping & Receiving

Supevision by Owner

Does the person do the following:

Cryptocurrency

Property

Policy Effective Period

Description of your Organization

Audit Procedures

Internal Controls

APPLICANT ACCEPTANCE/SIGNATURE