Nicholas Hill Group

Applicant (to be insured) Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person *

First Name

Last Name

Phone *

(###)

###

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Business Structure *

If other, please explain below

Corporation

Joint Venture

Partnership

LLC

Other

Insured Status *

For Profit

Not For Profit

Quote Need By Date *

MM

DD

YYYY

Has Applicant Had Insurance Coverage Previously *

If No, please provide an explanation below

Yes

No

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

If Yes, please provide an explanation below

Yes

No

Have you had any claims made against you or losses paid by your insurance company in the past 5 years? *

If Yes, please provide an explanation of all claims below

Yes

No

Has coverage ever been canceled or non-renewed during past 5 years for any of the above Special Events? *

Yes

No

Have you had any claims made against you or losses paid by your insurance company in the past 5 years for any of the above Special Events?

If yes, please provide an explanation of all claims below.

Yes

No

Do any of the above events include any of the following activities: Open Road Cycling, Use of ATV's, Bungee Jumping, Fire Dancing/Walking, Firearms/Riflery, Gymnastics, Inflatable Devices, Zip Lines, Mechanical Bulls, Motor Sports, Rappelling, Rock Climbing, Ropes Courses, Scuba Diving, Trampolines, White Water Rafting, All? *

Yes

No

Are you providing liquor for a profit?

Yes

No

Are you required to obtain a liquor license or permit for an event, meeting or function?

Yes

No

Will your annual liquor sales exceed $20,000?

If yes, please specify estimated revenue (in $) for liquor sales below.

Yes

No

Non-Owned/Hired Auto Liability Coverage

Limits of coverage: $300,000 per occurrence is only option provided

Yes, I would like to apply for Non-Owned/Hired Auto Liability Coverage

No, I would like to Decline this Offer

Does the insured have any owned automobiles?

If Yes, please provide the name of the insurer, current limits of coverage and effective date of coverage below.

Yes

No

If insured allows employees to use their own personal vehicles, indicate the frequency of use

Daily

Weekly

Monthly

Other (please provide details below)

To your knowledge, do individuals who regularly use their cars for business purposes carry minimum personal auto limits?

Yes

No

Do any of the above Additional Insureds require the Primary and Non-Contributory Endorsement? If so, please list those requiring this endorsement below. *

Yes

No

Do any of the above Additional Insureds require the Waiver of Subrogation Endorsement? If so, please list those requiring this endorsement below. *

Yes

No

Each Event and Additional Activity must install and collect a signed Release and Waiver of Liability, Indemnity Agreement and/or Assumption of Risk Form for all members, participants, volunteers and staff. Unintentional error on your part in securing Waiver and Release forms shall not void your coverage in the event of an occurrence to a participant or staff. However, your failure to maintain an adequate system to regularly secure Waiver and Release forms shall void your coverage in the event of an occurrence to a participant or staff. NOTE: Waiver and release program required for coverage. Do you agree to comply with this requirement? *

Please email a copy of the form that you use to [email protected]

Yes

No

A Risk Management Plan is required to purchase any of the above coverages. Do you agree to comply with this requirement? *

Yes

No

Signing this application and declaration does not bind either the application or the underwriter to provide the insurance. In the event there is any material change in the answers to the questions herein prior to the issuance date of the policy, the application form would be considered inaccurate or incomplete. The applicant will notify the insurer in writing, and, if necessary, any outstanding quotation may be modified or withdrawn. It is agreed that this application and declaration shall be attached to and form part of any policy which may subsequently be issued. To be signed by the Insured The undersigned applicant represents that the statements set forth in this application and its attachments and other materials submitted to the insurer are true and correct. In accepting any quotation provided by result of this proposal request, the insured warrants that all information and answers provided in this application are true and correct. Should an insurance policy be written, this application and any supporting information shall be incorporated into and form the basis of the written insurance policy. The Insured so warrants: *

Yes

No

By typing your name below, you are hereby agreeing to the terms outlined above and providing your personal warranty that all answers and responses that have been provided are true and accurate. Please note: All quotations are subject to the receipt and acceptable review of the application and other underwriting information by the underwriter. *

First Name

Last Name

Today's Date *

MM

DD

YYYY