Zipline Canopy Tours Liabilty Insurance Quote Form

zip line canopy tours insurance zipline insurance zipline liability insurance

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OUTFITTERS PROGRAM Description Page

Zip Line / Canopy Tours Quote Form

-   The "ENTER" or "RETURN" Key will submit the application.   Use the "TAB" Key and Mouse to navigate.
      If application is submitted by mistake, use the "BACK" Button on your browser to return to the application.
-   ALLOW 3 WEEKS to receive a quotation (LEAVING QUESTIONS BLANK WILL DELAY PROCESSING)
-   Available in all States
-    Click on Question Marks for further Explantions (Pop Ups)

GENERAL INFORMATION

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Legal Business Name:		Phone: This # isCell Biz Home
D/B/A Name:		Contact:
Mailing Address:		Fax:
City:	State: Zip:	Email:
County:	(NOT COUNTRY)	Website: www.
Type of Entity:	C Corp S Corp Partnership Sole Prop LLC Non-Profit Other:	Quote Need by Date : Three (3) weeks is normal lead time.
Year Business Established:	Years Experience in Field:	Federal ID #:
List All Owner(s) / Officer(s) Names:		Trade Associations you Belong to:PRCA ACCT Other:

Please provide a brief description of your operations & activities offered:

Operations Physical Address you OWN or LEASE (Address, City, State, Zip)
1.    Own Land or  Lease / Rent Land
2.    Own Land or  Lease / Rent Land
3.    Own Land or  Lease / Rent Land

POLICY / LIMITS INFORMATION

Have you ever had similar insurance cancelled or non-renewed?Y N

Have you or anyone else at your company already completed an insurance application in writing or over the phone for this insurance? Y N

  Who is your current Insurance "Company" (not your Agent): OR This is a New Business (SEE NEXT)

   FOR A NEW BUSINESS: Briefly describe your experience in this field, and also any business related experience you have:
    Click

for Example Template

If you have a policy in place, please answer following:
Expiration Date: Current Premium: Target Premium:(a competitive quote is this)

LIABILITY LIMITS SELECTION
LIMIT OF LIABILITY REQUESTED?
ADDITIONAL LIMITS (UMBRELLA) NEEDED OVER ABOVE $1,000,000?
DEDUCTIBLE REQUESTED?

GENERAL LIABILITY RATING INFORMATION PLEASE CLICK FOR RATING INSTRUCTIONS HELP
DESCRIPTION OF SERVICE PROVIDED	# OF CUSTOMERS PER YEAR	ANNUAL GROSS SALES
Zip Line / Canopy Tours:
Food & Beverage (No Alcohol):
Retail Sales (Briefly Describe What is Sold Below):
Alcohol Sales OR No Alcohol Sold or Offered
Lodging (Owned): # of Units Available for Rent:	Maximum Capacity?
Other:
Other:
Other:
IMPORTANT: # of Customers Per Year & Sales above MUST be entered for only your associated operation(s)? If these boxes are left blank we will not be able to provide you with a quote. Please use your best estimates if you are a new business. Also click here for more information.

SUPPLEMENTAL INFORMATION
- leaving questions blank will delay quote -

1. Other than the mentioned services in the above RATING SECTION are there any other operations that you provide? Y N If YES, Please describe:
2. What is your normal operating season? (month) to (month) or Full Year
3. Who / What Company built the course?
4. What Year was the course originally built?
5. Was it built to: ACCT or PRCA standards?ACCT PRCA If neither, whose standards?
6. How many ziplines does the tours consist of and length of each?
7. What is the maximum zipline height at your facility?Feet Single Line or Double Line Course? a. What is the maximum speed?
8. Does the course contain any bridges? Y N If YES, describe & how many?
9. Have you made any additions or alterations to the course since it was built?Y N If "YES", list date of change, type of alteration, or element name added, and construction vendor name:
10. Date of last course inspection by professional firm: Month / Year? Name of Firm?
11. How often is the course inspected by certified inspection company? Monthly Quarterly Bi-annually Annually Other:
12. What guidelines do you follow regarding zip line equipment retirement?
13. Do you maintain a written log documenting inspections of course elements?Y N and all related equipment?Y N
14. Have you made the recommended improvements on the course since the last professional inspection?Y N
15. What sort of braking system does your tour use?
16. Does your course require the participants to hand brake?Y N Please describe in detail the instruction given to participants? 17. Describe landing procedures for participants?
18. Are all participants required to wear gloves and helmets?Y N
19. Are participants harnessed prior to advancing to the top of the zipline platforms?Y N
19a. For Participants: What is Minimum age? What is minimum weight? What is maximum weight? How are weight requirements checked / enforced?
20. Do you provide any services after dark, including but not limited to, night ziplining and overnight camping functions?Y N If YES, please describe:
21. Do you provide transportation to/from your course?Y N If Yes, please describe: If YES, do you have an auto liability policy in place?Y N We need a quote for this.
FACILITY RENTAL - IF QUESTION #22 IS NO, SKIP TO QUESTION #23 22. Do you permit unguided or unsupervised use of your course(s)?Y N IF NO SKIP TO #23 If YES, please explain who would used and for what function (ie Parties, Banquets, Games, Special Events): Do you provide supervision when others rent your facilities?Y N What is the nature of the supervision? Total Gross Receipts from Course Rental? $ When others rent your facility, do you require certificates of insurance naming you as additional insured?Y N Do you use a hold harmless agreement with the contracting entity?Y N
23. Do you perform daily visual inspections of the course and equipment prior to use?Y N
24. Who provides your facilitator training? a. Do you have a certified and trained Course Director on Staff? Y N
25. Do you have any operations off your premise?Y N If YES, please decribe:
26. What is your staff to participant ratio?
27. Do you require all participants to sign a liability release / waiver, or assumption of risk form prior to participating in activities?Y N a. Do you require all participants declare they are fit to participate on your release / waiver, or have them complete a fitness form?Y N
28. Do you require a parent or legal guardian to sign on behalf of participants under the age of 18?Y N
29. How many years do you keep copies of signed waiver / release forms?Years OR Indefinitely
30. Was waiver and release form created and / or reviewed by an attorney familiar with local laws?Y N
31. Name of attorney/legal counsel who reviewed waiver? OR Not Applicable, No Review was done
32. Number of Staff? Full Time Part Time Seasonal Volunteers Contract Labor
33. What is your estimated total annual payroll?
34. Would you like a Workers Compensation Insurance Quote?Y N
35. Is a First Aid Kit Kept on Premises? Y N Miles to Nearest Emergency Medical Facility?
36. How many entities (such as a Landlord / Landowner) are going to require a certificate (proof) of insurance?
37. Do you have warning signs clearly posted addressing off-hours and non-authorized use of each course? Y N
PROPERTY SECTION If a quote is desired to cover the course and / or equipment
38. What is the Replacement Cost of your Course (to rebuild it from ground up)?
39. What is the Replacement Cost of all of your Equipment Associated with the Course (helmets, gloves, harnesses, etc)?
LOSS INFORMATION
NO CLAIMS PAST FOUR (4) YEARS OR ENTER CLAIMS BELOW
Date of Loss	Description of Loss	Amount Paid



The above information is correct to the best of my knowledge. Check: Initials: If Enter Button was pressed (Enter Button Submits the Form), use "Tab" key or Mouse to navigate. Submit Button is at bottom.
ADDITIONAL COMMENTS / NOTES
To Help us route your submission to the correct person in our office (if applicable): If you were referred to us, please tell us what company or person referred you: If you spoke to someone in our office, please tell us who:
FINAL ITEMS The above information may be enough to obtain a quotation, however, other items that may be requested prior to quoting, and will be needed if a policy is desired to be bound / issued. 1. Copy of Your Waiver / Release / Acknowledgement of Risk Form 2. Course Inspection (within one year) by an ACCT or PRCA Approved Vendor 3. Course Operation / Maintenance Manual or Guidelines 4. Diagram of Course if Website does not address
QUESTIONS / HELP - Contact Robb Gusic 440-639-9989 or Email: robb@thompsongusic.com Fax: 877-271-8898
Thompson - Gusic Insurance Group, Inc. 4067 Greensburg Pike \| Pittsburgh, PA 15221 412-271-8888 \| Fax 877-271-8898 www.thompsongusic.com
Click below to submit for a quote