Nicholas Hill Group

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

No

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 *

(###)

###

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Business Structure *

If other, please explain below

Corporation

Joint Venture

Partnership

LLC

Other

Insured Status *

For Profit

Not For Profit

Date of Incorporation or Charter *

MM

DD

YYYY

Desired Policy Effective Date *

MM

DD

YYYY

Policy Expiration Date *

MM

DD

YYYY

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

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

Yes

No

List all states where grooming work, activities/events/trail work are conducted in *

Please check all that apply.

AL

AK

AZ

AR

CA

CO

CT

DE

DC

FL

GA

HI

ID

IL

IN

IA

KS

KY

LA

ME

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

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

Yes

No

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

Yes

No

Does the organization hold any agreements to perform services? *

If Yes, please describe below

Yes

No

Please check all of the types of operations you conduct: *

Please provide detailed explanations for each activity below

Nordic Skiing

Rent Equipment

Sell Food and Beverages

Ice Skating

Back Country Skiing (guiding and/or access)

Sell or Repair Equipment

Lodging (rooms/cabins, yurts, etc.)

Facility Rental for Events

Snowshoeing

Lessons

Camping

Fat Biking

Snow Tubing or Tobogganing

Dog Sledding or Dogs Allowed

Other (please describe below)

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

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

Yes

No

Do you offer Mountain Biking in the off-season? *

Yes

No

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.

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

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 - 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

No

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

Yes

No

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

Yes

No

Does your club rent/lease vehicles for club purposes?

Yes

No

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.

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 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

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.

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.

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