Personal Information

Request Date     
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Establishment/Insured information
Name
Name of owner(s)
Address
City
Province
Country
Postal code
Phone number
Fax number     
E-mail
Web Site     

Years in operation with
current owner/operator

Affiliations
Provincial     
National     
Paid Membership     
Other     

Contact information
Name

Address information same as above

Address
City
Province/State
Country
Postal/Zip code
Phone number
Fax number     
E-mail

Agent/Broker information (if applicable)
Name     
Phone number     
Fax number     
E-mail

Desired coverage dates
Desired effective
Desired expiry


Applicant for this insurance is:

Individual Partnership
Corporation Joint Venture
Other (specify):       


Important

I hereby warrant and confirm that the above information, to the best of my knowledge, is true and correct, and further certify that I have read all of the questions and answers of this application.

I understand this application is a requirement for coverage, a part of the contract and evidence of my acceptance of this insurance, and any falsification or misrepresentation will be deemed a breach of contract, voiding all insurance coverage.

It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or to SportsInsurance until accepted by the company or companies in writing.


[Canadian] Adventure Tourism Request

Activities and Gross Receipts

Please indicate your activities, participants and gross receipts as requested.
If a new venture, please estimate:

Operation Yes No Total Participants Total Trip Days Gross Revenue Split
Canoeing/Kayaking 
Hiking/Backpacking 
Snowmobile/ATV 
Cross Country Skiing/
Snowshoeing 
Cycle Touring 
Rafting 
Trail Rides 
Sleigh/Wagon Rides 
Fishing 
Hunting 
Rock Climbing/Top Roping 
Dog Sledding 
Unsupervised side trips* 
Rentals:
Other (please specify): 
* Our program is designed for quided tours only. If your operations differ, please explain. (Please note, this may affect your eligibilty for insurance):     
Staffing Procedures

Please explain how each guide's certification, qualifications or experience is verified:     
Procedures for equipment and safety should be reviewed with your staff prior to each trip. Please confirm that this is your procedure. If any exceptions are made to this, please advise details of same.     
List all emergency first aid kits as well as emergency signal devices that you carry while on trips. It is required that a least one staff member have advance first aid training in case of medical emergency (broken arm / leg, etc.) Please explain your situation:     
Do you hire or employ anyone younger than 18 years of age? If so, please explain responsibilities of this person (or persons):     

Trip Information

Please indicate dates & participant/guide information for all trips scheduled for the season.
Start Date Finish Date Estimated Number
of Participants		 Number of Guides
                   
                   
                   
More

What is your minimum guide to participant ratio?     
Please outline educational information given to group prior to trip commencement.     
Do you have any overnight trips? Describe lodging:     

Participant Safety
   
Do you follow the standard safety measures as set by your governing body?     
Do you have a client (participant) package of information for safety issues, medical information, waivers, rules, regulations and clothing checklist for trips taken?     
Do you have a formal written safety program including safety equipment worn by participants while on a trip?     
Do you have an emergency evacuation process in place and an emergency communication system while on trip outings? Please explain.     
What is your policy regarding alcoholic beverages while on trips (during, before, and/or after)?     
Describe your food preparation facilities and methods while on outings.     
How is equipment transported or is it at site ahead of trip commencement? Please give details:     
Do you have owned/leased vehicles inspected by qualified mechanic?     
      If yes, is the inspection report logged into a permanent file
      in case of misadventure?     
Do you have a regular maintenance program in place to ensure vehicle safety is up to standards? Please explain:     

Automobile Exposures
                                                                        
Do you transport equipment and participants with your own or leased vehicles?     
      If yes, please explain:     
Limits of Insurance carried ($):     
Average lengths of road or vehicle travel:          
Type of road used: (Please hold [ctrl] for multiple selection)     
Do participants use their own vehicles as well?     
      If yes, please explain:     

Past Insurance History

Indicate limits carried corresponding premiums paid and total losses for the past five (5) years (attach Company Loss History--Verification if required).

Coverage Limit Premium Losses
                   
                   
                   
                   
                   
                                                                        
List and explain any losses that have been paid by any of your insurance policies:     
Name of Current Insurance Carrier:     
Has any Insurance Carrier ever cancelled or refused you or your business coverage?     
      If yes, please explain:     

To assist us to become more knowledgeable about your organization please provide us, by e-mail (e.g. scanned attachments) or fax (514-394-1180), the following information:

Copy of Yes No If no, explain
Letter of patent (if incorporated)     
Last financial statements     
All insurance policies     
Participant registration forms     
Waivers/Release forms being used     
Resumes & Certifications for each guide     
Any available advertising materials/brochures     
Credentials of those providing group instruction prior to trip commencement     
Participant trip information material for safety issues, medical information, waivers, rules, regulations and clothing checklist     
Formal written safety program including safety equipment worn by participants while on a trip?     

Please provide any additional information or remarks that may help us in evaluating your application:     

Desired Coverage
Type               Limits ($)
General Liability                   
Participant Legal Liability                   
Accident/Medical                   
Other (please describe):          


Supplementary Guide Information (Please complete one form for each guide)
Guide Questionnaire 1
                                                                                                         
General Information
Your position is:
Your name and address: 
Telephone Number:
Fax Number:

Experience and Certification
Years operating as Head / Ass't / Appren Guide:
Number of trips operating as Head / Ass't / Appren Guide:
Experience as a Guide: 
Is this a full time occupation? 
Please indicate number of hours worked per year:
Do you have wilderness first aid? 
Please indicate your level of first aid:
What are your certifications that qualify you to be a guide?: 
Does your certifying body require you to continue your education to maintain your certification? Describe: 
If not, do you pursue continuing education on your own? Describe: 
Please provide a copy of information on the certification program. 

 
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