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GENERAL RECREATION APPLICATION 04APR2019

Step 1 of 5

20%
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  • A. General Information

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  • B. Insurance History

  • Company name:Coverage:Limits:Annual premium: 
  • Company name:Expiration date:Annual premium: ($)Limits:Coverage type: 
  • Max. file size: 256 MB.
  • C. Desired Insurance

  • Limit of liability- Commercial Liability Coverage

  • D. Business Activities

  • Description of activityAnnual Gross ReceiptsAnnual no. of guests or participants (X)No. of days each person participated (=)Total user days 
  • Gross receipts: break out gross receipts by category. All others must be described or no coverage can be provided.

  • Last YearEstimated for this year 
  • Last YearEstimated for this year 
  • Last YearEstimated for this year 
  • Last YearEstimated for this year 
  • Please describeLast YearEstimated for this year 
  • Last YearEstimated for this year 
  • E. Equipment

  • F. Risk Management

  • Drop files here or
    Max. file size: 25 MB.
      *Carrier waiver may replace any existing waiver used
    • Drop files here or
      Max. file size: 25 MB.
        *Additional supplements may be required based on your operations.
      • G. Employees

      • Average:Minimum:
      • REPRESENTATIONS AND WARRANTIES

        The “Applicant” is the party to be named as the "Insured" in any insuring contract if issued. By signing this Application, the Applicant for insurance hereby represents and warrants that the information provided in the Application, together with all supplemental information and documents provided in conjunction with the Application, is true, correct, inclusive of all relevant and material information necessary for the Insurer to accurately and completely assess the Application, and is not misleading in any way. The Applicant further represents that the Applicant understands and agrees as follows: (i) the Insurer can and will rely upon the Application and supplemental information provided by the Applicant, and any other relevant information, to assess the Applicant’s request for insurance coverage and to quote and potentially bind, price, and provide coverage; (ii) the Application and all supplemental information and documents provided in conjunction with the Application are warranties that will become a part of any coverage contract that may be issued; (iii) the submission of an Application or the payment of any premium does not obligate the Insurer to quote, bind, or provide insurance coverage; and (iv) in the event the Applicant has or does provide any false, misleading, or incomplete information in conjunction with the Application, any coverage provided will be deemed void from initial issuance. The Applicant hereby authorizes the Insurer and its agents to gather any additional information the Insurer deems necessary to process the Application for quoting, binding, pricing, and providing insurance coverage including, but not limited to, gathering information from federal, state, and industry regulatory authorities, insurers, creditors, customers, financial institutions, and credit rating agencies. The Insurer has no obligation to gather any information nor verify any information received from the Applicant or any other person or entity. The Applicant expressly authorizes the release of information regarding the Applicant’s losses, financial information, or any regulatory compliance issues to this Insurer in conjunction with consideration of the Application. The Applicant further represents that the Applicant understands and agrees the Insurer may: (i) present a quote with a Sublimit of liability for certain exposures, (ii) quote certain coverages with certain activities, events, services, or waivers excluded from the quote, and (iii) offer several optional quotes for consideration by the Applicant for insurance coverage. In the event coverage is offered, such coverage will not become effective until the Insurer’s accounting office receives the required premium payment. The Applicant agrees that the Insurer and any party from whom the Insurer may request information in conjunction with the Application may treat the Applicant’s facsimile signature on the Application as an original signature for all purposes. The Applicant acknowledges that under any insuring contract issued, the following provisions will apply: 1. A single Accident, or the accumulation of more than one Accident during the Policy Period, may cause the per Accident Limit and/or the annual aggregate maximum Limit of Liability to be exhausted, at which time the Insured will have no further benefits under the Policy. 2. The Insured may request the Insurer to reinstate the original Limit of Liability for the remainder of the Policy period for an additional coverage charge, as may be calculated and offered by the Insurer. The Insurer is under no obligation to accept the Insured's request. 3. The Applicant understands and agrees that the Insurer has no obligation to notify the Insured of the possibility that the maximum Limit of Liability may be exhausted by any Accident or combination of Accidents that may occur during the Policy Period. The Insured must determine if additional coverage should be purchased. The Insurer is expressly not obligated to make a determination about additional coverage, nor advise the Insured concerning additional coverage. 4. The Insurer is herein released and relieved from any and all responsibility to notify the Insured of the possible reduction in any applicable Limit of Liability. The Insured herein assumes the sole and individual responsibility to evaluate, consider, and initiate a request for additional coverage or reinstatement of the annual aggregate Limit of Liability which may be exhausted by any single Accident or combination of Accidents during the Policy Period.
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      Evolution Insurance Brokers, LC ("EIB") is an excess and surplus lines insurance brokerage which is domiciled in and has its principal place of business in Sandy, Utah. This insurance product is offered by an unlicensed surplus lines insurer. The NPN for EIB is 5464658 and CA license number is 0H93938.

      The advertisement does not contain any assertion, representation, or statement with respect to the business of insurance or with respect to any person in the conduct of his or her insurance business, that is untrue, deceptive, or misleading, and that is known, or that by the exercise of reasonable care should be known, to be untrue, deceptive, or misleading.

      Statements made regarding insurance coverage are for general description purposes only and they do not amend, modify, supplement, or alter any insurance policy in any way, including but not limited to claims purposes, nor do they provide details regarding terms, conditions, coverage, exclusions, or services of any insurance policy. Policy eligibility is subject to underwriting qualifications and approval by the insurance company writing the policy. Contact EIB for more information.

      All information, content, and materials available on this site are for general informational purposes only. This information does not, and is not intended to, constitute legal advice on any particular set of facts or circumstances, and may not constitute the most current legal developments. No user or browser of this site should act or refrain from acting based on the contents of this site without first seeking legal advice from counsel in the appropriate jurisdiction. This website may also contain links to content from third-party web sites which are intended only as a convenience for the user or browser and are not necessarily recommended or endorsed by Prime Holdings Insurance Services, Inc. and its affiliates. All liability with respect to actions taken or not taken based on the contents of this site are hereby expressly disclaimed. The content on this website is provided ""as is"" and no representations are made that the content is free of errors.

      By submitting an application through this site, you acknowledge that certain personal data disclosed as part of the application process is necessary for purposes of evaluating and issuing insurance products to you by the insurer and its affiliates and you hereby consent to the insurer and its insurance affiliates processing such information. You understand that the insurer may share the information disclosed as part of the application process for purposes of evaluating and issuing insurance products and risk management services (including to the producer listed on the application), but that the insurer will not disclose your personal information to unaffiliated advertisers or vendors. You acknowledge that you have the right to withdraw your consent to the insurer's use of your personal data that is deemed by the insurer to be unnecessary for the purposes stated above by notifying us in writing.

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