GENERAL APPLICANT INFORMATION

Please note, although we allow you to submit your Organization's General Liability Application and your Special Event Liability Application using this single form, if approved, you will be issued separate policies for your Organization's coverage and any Special Event coverage needed. Submission Requirements:  Completed signed / dated Application (this form)  Attestation of no prior claims; or if prior claims, a currently valued insurance company loss for prior 4 years  Sample lease agreement or memorandum of understanding if do work on other’s premises (e.g. grooming, trail building or maintenance)  If other named insureds are to be included, attach list and describe operations of each Once all of the required information is submitted, it generally takes a minimum of 10 business days to obtain quotes. Domicile states of NY, OK, PA & WA and/or large accounts may require additional time and include a $2,000 minimum premium.

NORDIC CENTER / CROSS COUNTRY SKI ORGANIZATION LIABILITY INSURANCE

Premises Coverage Limitation Disclaimer

The Nordic Center Insurance Program is designed to offer coverage for ON-PREMISES Nordic center operations only. Off-Premises Coverage is subject to an additional charge and is available for off-premise activities associated with Nordic ski teams, hiking, running or any non-athletic activities such as fundraisers, marketing at community events, etc.” Coverage limits are included within the standard program general liability limit. To apply for Off-Premises Coverage, you must do so by adding it in the Optional Coverages section below.

I hereby understand

Is your Organization a current member of the Cross Country Ski Area Association (CCSAA)?

CCSAA membership must be confirmed to receive the member benefit.

Yes

Name of Applicant (to be insured)

Applicant (to be insured) Physical Street Address or PO Box

We must have a physical address or PO Box before we can provide coverage for your organization.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant (to be insured) Mailing Address

We must have a mailing address before we can issue a policy for your club. Mailing address is therefore a mandatory field.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person

First Name

Last Name

Phone

(###)

###

####

Business Structure

If other, please explain below

Corporation

Joint Venture

Partnership

LLC

Other

Insured Status

For Profit

Not For Profit

Federal ID #

Date of Incorporation or Charter

YYYY

State where Charter or Corporation is filed

Desired Policy Effective Date

YYYY

Policy Expiration Date

YYYY

Quote Need By Date

YYYY

Has Applicant Had Insurance Coverage Previously

If No, please provide an explanation below

Yes

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

If Yes, please provide an explanation below

Yes

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

Total Annual Revenue

Include all operational income and charitable donations

Does the organization groom, build and/or maintain trails?

Yes

If the organization grooms, builds or maintains trails, how many total kilometers of trail?

Please include your organization's responsibilities (do you groom, build, maintain, etc.)

Do you use a 3rd party subcontractor to groom your trails?

Yes

Does the organization build or maintain trails with technical trail features (TTFs) such as bridges, ramps, etc?

Yes

Does the organization hold any agreements to perform services?

If Yes, please describe below

Yes

Do any of the above activities take place off-premises?

Off-premises means any location other than the actual nordic center?

Yes

Please provide detailed explanation(s) for each activity you conduct from the above list. Please include whether the activity takes place on or off premises.

Do you offer Mountain Biking in the off-season?

Yes

What other activities do you offer in Spring, Summer and Fall?

Please provide detailed explanation for all activities below. Please include whether the activity takes place on or off premises.

Option: If you require additional policy limits ($1,000,000) for Products / Completed Operations coverage, please check here. There will be a premium surcharge for this additional coverage.

Yes, I would like to apply to increase the products / completed operations limit to $1,000,000.

No, I would like to Decline this Offer.

OPTIONAL COVERAGE - LIQUOR LIABILITY

Complete this section if you need a quote for Liquor Liability. If you do not need this coverage, skip this section.

Liquor Liability Coverage

Note: Host Liquor Liability Coverage is automatically included with your General Liability Policy. However, if you answer yes to any of the above 3 liquor liability related questions, we recommend you answer "yes" below and apply for Liquor Liability Coverage.

Yes, I would like to apply for Liquor Liability Coverage - if yes, please answer the liquor liability questions below.

No, I would like to Decline this Offer - if declined, you can skip the following liquor liability questions.

Are you providing liquor for a profit?

Yes

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

Yes

Will your annual liquor sales exceed $20,000?

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

Yes

OPTIONAL COVERAGE - NON-OWNED/HIRED AUTOMOBILE COVERAGE

Coverage is ineligible for 12+ passenger vans and U-Haul’s, Penske’s, box trucks, etc.

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 - if declined, you can skip the following Non-Owned/Hired Auto Liability questions.

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

Do members to use their own person vehicles for club purposes?

Yes

If yes above, how many members use their personal vehicles?

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

Yes

Does your club rent/lease vehicles for club purposes?

Yes

PLEASE NOTE - Coverage is not eligible for 12+ passenger vans or U-Haul’s, Penske’s, box trucks, etc.

I understand coverage is not eligible for 12+ passenger vans or U-Haul’s, Penske’s, box trucks, etc.

OPTIONAL COVERAGE - INLAND MARINE (EQUIPMENT) COVERAGE

Inland Marine coverage provides protection against your equipment being physically damaged as the result of broadly specified perils.

Inland Marine Coverage

Yes, I would like to apply for Inland Marine Coverage - if yes, please answer the inland marine questions below.

No, I would like to Decline this Offer - if declined, you can skip the following Inland Marine coverage questions.

Please provide the replacement cost values regarding your equipment below

Small hand tools

Total value of all other equipment not valued over $1000

Please list any equipment valued over $1,000 below - must include description/name of the equipment, value and address where located/garaged. NOTE: Trailers licensed and plated for road use cannot be insured under this inland marine coverage - they should instead be insured under a separate automobile policy. We can only offer coverage for the contents of the trailer. Stationary trailers that are not licensed and plated for road use can be included for property damage coverage under this optional inland marine coverage.

OPTIONAL COVERAGE - Auto Liability & Physical Damage (owned autos), Property Coverage (for buildings/structures they own or are required to insure) and/or Excess Liability - Note: passenger vans of any size are not accepted.

Complete this section if you need a quote for any of the following coverages. Property coverage for lodging buildings is subject to underwriter approval. Private residences are NOT intended to be covered through this program, only buildings with uses related to regular business operations.

Please check all that apply.

Auto Liability (owned autos) Please note: We can offer physical damage for vehicles but typically liability only on older vehicles.

Property Coverage (for buildings/structures they own or are required to insure). Property coverage for lodging buildings is subject to underwriter approval. Private residences are NOT intended to be covered through this program, only buildings with uses related to regular business operations.

Excess Liability (and if so, specify limit needed - please specify either $1,000,000 or $2,000,000 below)

$1,000,000 limit

$2,000,000 limit

Pease provide detailed information for any owned autos or property you wish to cover below. Auto coverage details must include: - A complete list of drivers with drivers license numbers and date of birth - Full list of vehicles needing coverage. Must include VIN numbers, year, make/model and values Property coverage details must include: - Building values for all buildings - Completed property Acord apps for cabins/lodging buildings to be considered - email [email protected] if you need an Acord form sent to you - Full schedule of locations and buildings for submissions with multiple locations and/or SOV (schedule of values) spreadsheet emailed to [email protected]

OPTIONAL COVERAGE - SPECIAL EVENT PARTICIPANT ACCIDENT MEDICAL COVERAGE

Please Note: General liability coverage is provided for special events under the general liability policy for the Nordic Center. This is optional participant accident medical coverage available for particpants of your special event(s). Standard coverage includes $10,000 medical maximum with a $50 deductible, $5,000 Accidental Death & Dismemberment maximum.

Special Event Participant Accident Coverage

Yes, I would like to apply for $10,000 maximum special event(s) participant accident medical coverage (includes a $50 deductible), $5,000 accidental death & dismemberment coverage.

No, I would like to decline special event(s) participant accident medical and accidental death & dismemberment coverage.

Please provide event name, event dates and number of participants for each event you wish to add special event participant accident and accidental death & dismemberment coverage for in the space below.

OPTIONAL COVERAGE - OFF-PREMISES LIABILITY COVERAGE

Off-Premises Coverage - Coverage is subject to an additional charge and is available for off-premise activities associated with Nordic ski teams, hiking, running or any non-athletic activities such as fundraisers, marketing at community events, etc.” Coverage limits are included within the standard program general liability limit

Off-Premises Liability Insurance Coverage

Yes, I would like to apply for Off-Premises Liability Coverage for an additional cost of $5.00 per participant/member.

No, I would like to decline Off-Premises Liability Coverage.

Please provide all details, including full description of all Off-Premises activities as well as the number of participant or members participating in each Off-Premises activity that is listed.

ADDITIONAL INSUREDS

Please add any additional insureds that are required for any of the coverages that you are applying for below

Cross Country Ski Areas Association (CCSAA)

Cross Country Ski Areas Association is automatically added as an Additional Insured to all policies

Add Additional Insureds below

To add Additional Insureds, please include the following for EACH Additional Insureds - Legal Name, First Name, Last Name, Address, City, State, Zip Code, Email, Relationship to the Insured (Venue, Municipality, Contractor, etc.), Description of Operations and any required certificate verbiage.

Do you have: (a) Any further material facts to disclose (material facts which might influence the acceptance or assessment of the application); OR (b) Any special non-standard request for coverage which you wish underwriters to consider? Please enter any material facts or special coverage requests below: *

Please provide details or type "NO" below

PLEASE READ AND SIGN (By typing your name) BELOW:

It is recommended that, when possible, all Nordic Center clients collect releases/waivers. Please contact us if you have any questions or want assistance in doing so.

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

THIS WARNING IS PART OF YOUR APPLICATION/QUOTATION. PLEASE READ IT CAREFULLY.

STATE SPECIFIC FRAUD WARNINGS GENERAL STATEMENT GENERAL STATEMENT Any person who knowingly and with intent to defraud any insurance company or another person files an application/quotation for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied). APPLICABLE IN COLORADO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE in THE DISTRICT OF COLUMBIA Warning: it is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. APPLICABLE IN FLORIDA Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. APPLICABLE IN HAWAII For you protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. APPLICABLE IN KANSAS Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. APPLICABLE IN MASSACHUSETTS, NEBRASKA AND OREGON Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. APPLICABLE IN MINNESOTA Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN NEW HAMPSHIRE Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. APPLICABLE IN OHIO Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA Warning: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. APPLICABLE IN VERMONT Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law. APPLICABLE IN WASHINGTON It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

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

YYYY

Please note: this Organization and/or event insurance application(s) is subject to full underwriting. The decision to provide a quote or not is, in part, determined by the answers you have provided in the above application. Should a policy be issued, it will include certain exclusions and limitations. It is the applicant/insured's responsibility to read and understand the terms in any policy that is issued and bound. Not all insurance products are available in all states. Please contact the Nicholas Hill Group, Inc. by emailing [email protected] with any product questions. All insurance products are provided by licensed representatives.

Agent Signature: Ryan E. Hill

Agency: Nicholas Hill Group, Inc.

Nordic center and cross country ski operation LIABILITY INSURANCE APPLICATION

Nordic center and cross country ski operation
LIABILITY INSURANCE APPLICATION