Basketball Insurance Questionnaire

Basketball Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
Basketball Teams | Basketball Clubs | Basketball Leagues | Basketball Camps | Basketball Clinics | Basketball Tournaments | Races
GENERAL INFORMATION
1. Liability Coverage (check coverage desired):

General Liability – including injuries to participants
GL Occurrence Limits desired:
GL Aggregate Limits desired:
2. Do you want abuse and molestation coverage (available for youth leagues)?

YesNo
3. Participants' medical payments: (select one)

$1,000$2,500
4. Please list locations and buildings at each location (List additional locations on separate page)
Location 1: Address and number of buildings
Location 2: Address and number of buildings
OPERATIONS
1. Dates of operation:
2. Age of participants/members (check one or both):

Under 1919 or older
3. Please indicate membership or affiliation with any state, national and/or international association/organization:
4. Do you require participants/members (or parents of minors) to sign an injury waiver? (Please provide a copy.)

YesNo
5. What methods of instruction do you use?

GamesDrillsLecturesOther
5a. Describe "Other "
6. What equipment do you provide?
7. Is play/instruction?

OutsideInsideBoth
8. Are the facilities inspected before every session?

YesNo
9. Whose rules and official guidelines do you follow?
10. In the event of unsafe facility conditions, who has the authority to cancel the event?
11. Who maintains the portion of the facility that you use?
12. Who checks the condition of the facility before each session, practice or game?
13. Is proper footwear required?

YesNo
14. Are the backboards shatterproof?

YesNo
15. Are the hoops collapsible?

YesNo

16. How much clearance is there beyond the:

	Distance (feet)
Endlines
Sidelines

17. Is play stopped if it becomes too aggressive?

YesNo

	Yes	No
4a. Abuse and Molestation?
4b. How to recognize the signs of abuse?
4c. What to do if an individual reports someone molested him/her?

	Number
1a. Number of teams participating:
1b. Total number of games:
1c. Approximate number of participants:
1d. Approximate number of spectators:

	Start Date	End Date
Camp 1
Camp 2
Camp 3
Camp 4

	Day Only	Day & Overnight
Baseball/Softball
Basketball
Bowling
Football (no tackle)
Soccer
Swimming
Tennis
Volleyball
Wrestling
Other (Describe below)

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2
Building 3

	Yes	No
1a. On prospective employees and volunteers?
1b. On existing employees and volunteers?

	Number
1a. Approximate number of participants:
1b. Approximate number of spectators:

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

	Name	Position	Qualifications/Experience/Certification
1
2
3

	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3