Climbing Walls Insurance Questionnaire

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

Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
GENERAL INFORMATION

Please provide copies of the operations/safety/training manuals, which include procedures for: Equipment/wall inspection, proper belaying techniques/certification, setup and takedown, belay device failure or entrapment, emergencies and reporting problems.
1. Describe your operations including a complete list of activities. Please attach a flier if available.
2. What are the annual gross sales from this operation?
3. How many climbers annually?
4. How many walls are being used? Please provide photos of climbing wall(s).
5. What is the height and width of the climbing wall(s)?
6a. If the walls are portable, how are walls transported?
6b. If the walls are portable, does the operator stay with the walls?
7. If walls are stationary, are the walls part of another operation?
7a. If yes, what type of operation? (If yes, please submit a Certificate of Insurance for the rest of the risk. )
8. Do all climbers sign waivers? (Please provide copies of waiver, release or consent forms.)
9. What is the minimum age allowed?
9a. If under 18 years old, do parents or guardians have to sign the waiver also?
10. Do you allow climbers to use personal equipment?
10a. If yes, describe your policy with respect to screening of personal equipment used by others:
11. Are all belayers certified/trained?
12. What type of belay device is used?

12a. If an auto belay device,

Rows	Enter info below
How old is the device?
Date of last inspection
Who is manufacturer

13. Is there a minimum of 6 to 12 inches of fall protection beneath the climbing wall out to a distance of 6 to 8 feet?
14. What type of material is used in the landing area?
15. Is a daily inspection of the wall performed and results documented?
16. Is wall maintenance conducted by an independent contractor who provides you with a certificate of insurance?
17. Is all climbing safety equipment inspected, with inspection results documented?
18. Are safety rules posted? (Please provide rules for the climbing wall.)
20. Is a full-time staff member positioned to have a clear view of the climbing wall and participants?
21. Do you ever hire sub-contractors/independent contractors that carry their own insurance?
21a. If yes, please provide details:
21b. If yes, are certificates of insurance provided?
21c. Do you require contractors to name you as additional insured on their policy?
21d. Total Cost:

Rows	Enter number below
Concession Receipts ($)
Number of Stands
Square Footage

Rows	Enter Number Below
Ranges
Ovens
Deep Fryers
Grills
Broilers
Griddles

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

Rows	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?

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

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

Rows	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible