PREMISE LIABILITY INFORMATION Club Name: Club Address: Is premises owned or leased: # Acres of Land: Location Address: Legal Description: Do club trails cross premises: Special Features regarding terrain: (Such as lake, pond, race track, etc. – give details) How often are club activities held on the premises: What types of activities: Is the premises available to club members for activities (other than club related): For what purpose and how often: Is the premises available to other than club members: For what purpose and how often: # of Buildings on the premises: Construction of buildings and measurements: Usage of buildings: Kitchen facilities Explain: Cooking: Explain: Sleeping Quarters: Explain: Do you currently have a premises liability policy in force to cover the above exposures: If yes provide: Insurance Carriers: Policy # Policy Dates: To Do you want a club quote including a premises liability exposures noted above: Yes No If you are requesting a quote need the following information completed also: Previously insured: Company: Dates of coverage: Losses: Details of Losses: Signature: Date:
PREMISE LIABILITY INFORMATION Club Name: Club Address: Is premises owned or leased: # Acres of Land: Location Address: Legal Description: Do club trails cross premises: Special Features regarding terrain: (Such as lake, pond, race track, etc. – give details) How often are club activities held on the premises: What types of activities: Is the premises available to club members for activities (other than club related): For what purpose and how often: Is the premises available to other than club members: For what purpose and how often: # of Buildings on the premises: Construction of buildings and measurements: Usage of buildings: Kitchen facilities Explain: Cooking: Explain: Sleeping Quarters: Explain: Do you currently have a premises liability policy in force to cover the above exposures: If yes provide: Insurance Carriers: Policy # Policy Dates: To Do you want a club quote including a premises liability exposures noted above: Yes No If you are requesting a quote need the following information completed also: Previously insured: Company: Dates of coverage: Losses: Details of Losses: Signature: Date:
PREMISE-LIABILITY-APP-fillable.docx