SRA Application | Special Risk Associates

Let's get to know you.

Please fill in the details below so that we can get in contact with you.

Full legal name of the proposed policyholder

Type of organization

Please clarify

Are you operating under a DBA name? If so, please enter.

Mailing Address

City

State

Zip code

Full contact name

Phone number

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General Information

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What is your primary business activity?

Select the category that best describes your operations so we can provide the correct coverage options.

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Coverage Type

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Industry Specific Details

Please complete the following application sections. As activities vary, some questions may not be applicable; please indicate N/A where necessary.

General Information

Requested effective date

Policy will become effective on the Requested Effective Date if (a) all required information is provided and (b) the Company has received the initial premium on or before that date. 12 months of coverage is
provided.

Would you like to add General Liability Coverage?

This coverage requires an accident medical policy with at least a $10,000 medical expense benefit issued through Special Risk Associates.

Would you like to add coverage for any hosted events?

Is your current insurer non-renewing coverage?

Do you currently have a risk management plan?

Does your organization currently utilize a waiver system?

Type of organization

Do you own or operate any sports fields, courts or facilities on a 24-hour basis?

Does your organization have other sports outside Baseball, Softball or T-ball?

Have any liability claims been paid by your insurer during the last 3 years?

Please describe

Are all of the following statements true?

(a) None of my players are compensated/paid to participate in my sports organization.
(b) My organization is NOT school-sanctioned.
(c) No activities are held on residential property.
(d) No activities take place at a pool that I own, operate or manage.

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General Information

Full facility address

Website

Date of formation

Person responsible for general operation of activities

Years and type of experience

Effective date

Hours of operations

Annual payroll

Number of employees

Average annual attendance

Annual gross receipts

Square footage of facility

Do you run criminal background checks on employees?

Does the application have a formal safety training program for employees?

Does the applicant have surveillance cameras?

Does applicant have central station fire and burglar alarm?

Does your facility include an air supported structure and/or dome?

Does the applicant have an automatic extinguishing system over deep fat fryers, grills, & stoves?

Are rules posted conspicuously and enforced at all times?

Are incident reports completed and maintained for all injures, regardless of severity?

Are participants required to sign a Waiver & Release of Liability for all activities? If yes, please provide a copy.

Are copies of the Waiver & Release of Liability kept on file?

Are the referees or coaches employees of your organization?

Do you currently have a risk management plan?

Are facility/playing field inspections and maintenance performed?

Are parking lots well-lit and patrolled?

Is a log kept of inspections and maintenance performed?

Does the facility rent or repair sports equipment?

Are written emergency procedures in place? If yes, please submit copy.

Is the facility locked so that patrons cannot use it when closed?

Do you provide childcare on site?

Is your current insurer non-renewing coverage?

Have any liability claims been paid by your insurer during the last 3 years?

Please describe

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General Information

Event name

Event location(s)

Requested effective date

Vendor type

Explain if other vendor type selected

Description of your exhibit/goods

General Liability

Will your exhibit or goods involve any use of fire other than cooking, fireworks or firearm ammunition?

Has your past liability coverage been canceled in any way in the last three years?

Is your current insurer non-renewing coverage?

Have any liability claims been paid by your insurer during the last three years?

If yes, describe claims

Will your exhibit include mechanical or inflatable amusement devices?

Are all of the event operations to be insured located within the United States?

Have you or your company ever been involved in any legal dispute relating to the operations or products of your company or business?

Do you operate any of the following?
Body piercing or tattooing, Catering Companies, Christmas tree retail lots, Corn or Hay maze, Disc-Jockeys for events with over 200 attendees, DJ Companies with more than 1 Employee, E-commerce selling, Entertainment and Film Industry Vendors, Fire Dancing, Fire Eating, Food Trucks, Haunted attractions, Hot wax impressions, Live Edge Weapon Performers, Live animals, Live Bands with more than 1 individual, Marijuana and other cannabis products and/or paraphernalia, Massage, medical testing, Motor sports activities, Nutritional/health supplements, On-site installation/service/repair of products, On-site equipment rental, Oxygen/aromatherapy, Storefront operations, Timeshare sales, Tobacco products, Vehicles in motion, Watercraft exhibits on water, Weapon Throwing, Weapon sales, Weight-loss plans or products, Wholesale business.

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General Information

Requested effective date

Termination date

Policy will become effective on the Requested Effective Date if (a) all required information is provided and (b) the Company has received the initial premium on or before that date

Apply for

Teams Information

Team #1

Sport activity

Age group

Total number of players

Team #2

Sport activity

Age group

Total number of players

Team #3

Sport activity

Age group

Total number of players

Team #4

Sport activity

Age group

Total number of players

General Liability

Has your past liability coverage been canceled in any way in the last three years?

Does your organization currently utilize a waiver system?

Does your organization currently have a risk management plan?

Is your current insurer non-renewing coverage?

Have any liability claims been paid by your insurer during the last 3 years?

If yes, describe claims

Do you own or operate any sports fields, courts or facilities on a 24-hour basis?

Does your organization have other sports outside of the selected above?

Is anybody of your players compensated/paid to participate in your sports organization?

Is your organization is school-sanctioned?

Are any activities held on residential property?

Do any activities take place at a pool that you own, operate or manage?

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Application Requirements

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Acknowledgment and Signature

Please digitally acknowledge the terms below.

Signed for the Proposed Policyholder

Date

a. This summary of coverage and exclusions is no substitute for reading the entire policy. To receive an entire policy, contact the program administrator.
b. Waiver Requirement Each organization or team must implement a Release and Waiver of Liability and Indemnity Agreement for all players 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 player or staff member. 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 player or staff member. A sample waiver and release form is available upon request.
c. Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other 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 there to, commits a fraudulent insurance act, which may be a crime.
d. Applicant’s Acknowledgement I, the applicant, declare, to the best of my knowledge and belief, that all statements and answers in this application are true and complete. I understand and agree that
(a) this application will form part of any policy issued,
(b) no information given to or acquired by any representative of the Company will bind it, unless it is in writing on this application,
(c) no waiver or modification will bind the Company unless it is in writing and is signed by an executive officer of the Company, and
(d) only those persons eligible under the terms of an issued policy will be insured.

Acknowledgment

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