Scottsdale Insurance Company Adm. Office: 8877 North Gainey Center Drive Home Office: One Nationwide Plaza Scottsdale, Arizona 85258 Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale Surplus Lines Insurance Scottsdale, Arizona 85258 Company Adm. Office: 8877 North Gainey Center Drive Scottsdale Indemnity Company Scottsdale, Arizona 85258 Home Office: One Nationwide Columbus, Ohio OUTFITTERS AND GUIDES PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant’s Name: Agency Name: Agent No.: Location Address: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT INDICATE APPLICABLE” (N/A) “NOT 1. Description of operations: 2. Errors and Omissions (E&O) Coverage (available up to General Liability Limits): Each Claim: $ Aggregate: $ 3. Type of license (if applicable): 4. Applicant’s prior experience: 5. Does applicant’s operation involve any of the following: Aircraft exposures? Yes No • Unmanned aircraft systems (drones)? Yes No • ATVs/UTVs tours? Yes No • ATVs/UTVs hourly/daily rentals? Yes No • ATVs/UTVs provided by applicant and used for hunting/fishing trips? Yes No • If yes: Number of ATVs/UTVs: Bicycle using public roads? Yes No • Boats? Yes No • If yes: Number of canoes, kayaks and rowboats: Number of rafts: Number of motorized watercrafts: Number of boats over twenty-six (26) feet: Number of boats over 150 hp: Does applicant provide each boat passenger with a U.S. Coast Guard approved personal flotation device? Yes No Deep sea fishing? Yes No • Dogsleds? • Yes No Downhill skiing? Yes No • Firearms or ammunition provided by applicant? Yes No •
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide Columbus, Ohio Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 OUTFITTERS AND GUIDES PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant’s Name: Location Address: Agency Name: Agent No.: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT INDICATE “NOT APPLICABLE” (N/A) 1. Description of operations: 2. Errors and Omissions (E&O) Coverage (available up to General Liability Limits): Each Claim: $ Aggregate: $ 3. Type of license (if applicable): 4. Applicant’s prior experience: 5. Does applicant’s operation involve any of the following: • Aircraft exposures? Yes No • Unmanned aircraft systems (drones)? Yes No • ATVs/UTVs tours? Yes No • ATVs/UTVs hourly/daily rentals? Yes No • ATVs/UTVs provided by applicant and used for hunting/fishing trips? Yes No If yes: Number of ATVs/UTVs: • Bicycle using public roads? Yes No • Boats? Yes No If yes: Number of canoes, kayaks and rowboats: Number of rafts: Number of motorized watercrafts: Number of boats over twenty-six (26) feet: Number of boats over 150 hp: Does applicant provide each boat passenger with a U.S. Coast Guard approved personal flotation device? Yes No • Deep sea fishing? Yes No • Dogsleds? Yes No • Downhill skiing? Yes No • Firearms or ammunition provided by applicant? Yes No
Outfitters%20&%20Guides%20Supplemental%20Application.docx