GENERAL LIABILITY APPLICATION
Recreation Insurance Association

 
General Information
Name Insured(s):
Address:
City:    State:    ZIP:
County:   Contact:
Phone:                             Fax:
Business Established: What year?                                     Email:
Insured is: Corporation  Partnership  Sole Proprietor
Business Description:
Current Insurance Carrier (not agency):
Company Name:
Policy Exp. Date: (mm/dd/yyyy)
Annual Premium: $
Loss Information: 
Date of Loss:
(mm/dd/yyyy)		 Description  Amount Paid
$
$
$
(This information is accurate to the best of my knowledge)
OFF WATER OPERATIONS
Retail Revenues Rentals Revenues Activities Revenues
Lodging $ Caving $ Climbing Wall $
Gift Shop (T-Shirts, etc) $ Bikes $ Rock Climbing $
Food $ Snowmobiles $ Ropes Course $
Beer & Liquor $ Snow Skiing $ Paint Ball $
Camping $ Horses $ Other $
WATER OPERATIONS - RENTALS ONLY
Gross Receipts: Canoes Rafts Kayaks River(s) Name
Class I, II & III $ $ $
Wet Suits $      
WATER OPERATIONS - GUIDED TRIPS, INSTRUCTION, TOURS
Gross Receipts: Canoes Rafts Kayaks River(s) Name
Class I, II & III $ $ $
Class IV, V $ $ $

Is a signed waiver obtained from your customers?

yes     no
If so, include Risk Acknowledgement?
yes     no

Do you offer a "safety talk" to your customers?

yes     no

If guided tours are offered, are all guides qualified in CPR?

yes     no

Are U.S. Coast Guard approved life vests worn by
customers while on watercraft?

yes     no
Please give any additional comments about the coverage you desire:
 
Would you also like a quotation for:
  Auto   Property   Umbrella   Worker's Comp   Crime
 

Thank you for your time in submitting your Application. We will contact you within 10 days with a proposal.  Any questions, please call
Mike Fetchero or Alice Harman at 800-624-5914.