Ropes Course Supplemental Application

gClimbing Outfitters & Guides Insurance

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OUTFITTERS PROGRAM Description Page

Ropes Course Supplemental App

- THIS APPLICATION IS TO BE USED IN CONJUNCTION WITH ANOTHER QUOTE FORM SUCH AS THE
    "OUTFITTERS LIABILITY" OR "CLIMBING GUIDES" APPLICATION. A QUOTE CANNOT BE OBTAINED
    FROM THIS APPLICATION BY ITSELF.

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Your Business Name:

REMINDER: THIS APPLICATION WILL BE MATCHED TO PREVIOUSLY SUBMITTED INFORMATION BY YOUR BUSINESS NAME.

By whom was the ropes course designed?

Who constructed the ropes course? What date was it constructed?

How often is the course inspected? Monthly Quarterly Annually Other:

A Copy of the most recent (within 1 year) "passing" inspection report will be needed.

What percentage of the ropes course is: High Element Low Element

Are there any Portable Elements Used? No Yes, Explain:

What is total # of instructors (Including Directors)?

Is the course director certified? Yes    No
    Certified by Whom (Name)?
    Date of last accreditation class or related courses completed?

How many assistant instructors are certified? By Whom?
If not certified, describe training required?

What is the ratio of participants to instructors? What percentage of participants are under 18 year old?

What is total # of estimated participants for the year? What are expected total revenues from Ropes Course Only?

What is the minimum age of participants? What is the maximum age of participants?

Do you provide services to the Mentally or Physically challenged, or Troubled Youth Organizations? Yes No

Do you provide overnight camps for children 18 years or younger? Yes No

Is a signed Waiver / Release / Assumption of Risk form obtained from all customers including parent/guardian if participant is a
minor? Yes No

Please provide a copy of this form, if not already provided.

Course Rented
Is the course ever rented "by your business" to outside groups or individuals? Yes    No, If No Skip next 2 Questions.
   Do you provide the supervision with your instructors / guides to the participants? Yes    No
   Estimated # of participants of rented course periods:   Sales generated from rented course periods:

Please provide a copy of this rental agreement, if not already provided.

Does your business do any of the following (check all that apply)
    Course Design/Construction    Site / course accreditation / certification Instructor Certification
    Ropes course supplies / accessories sold --- Types of products sold:
          Are all products in compliance with ACCT standards? Yes    No     Estimate product sales per year:

How far is the nearest hospital or emergency medical facillity?Miles

FINAL
Has a previous application been submitted for your remaining business / operations information?Yes No

FORMS: Supplemental Forms or Reports can be Faxed to either (877) 271-8898, or (412) 271-8898,
or Emailed to insurance@thompsongusic.com
or Mail to: Thompson - Gusic Insurance Group, 2140 Ardmore Blvd, Pittsburgh PA 15221

COMMENTS

The above information is correct to the best of my knowledge. Check: Initials:
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QUESTIONS / HELP	Call our staff and ask for help.
Email:	insurance@thompsongusic.com
Phone:	(412) 271-8888 (9 - 4:30 EST) Out-of-State (PA): (888) 944-8398 (888)WHITE-WT
Fax:	(877) 271-8898