LIO Amateur Sports Application

1. Producer & Submission Info

Brokerage / Agency

Producer / Broker Name

Producer Email

Producer Phone

Desired Effective Date *

Expiration Date *

Tax Status *

For-Profit Non-Profit

2. Named Insured

Named Insured (Legal Name)

Primary Contact

Phone

Email Address

Website

Mailing Address

Street Address

Street Address 2

City

State

Zip Code

3. Risk Location

Enter the primary location where operations or administrative offices are based. If same as mailing address, check below.

Same as mailing address

Street Address

City

State

Zip Code

4. Coverage Requested

Lines of Coverage

General Liability (including Participant Legal Liability) Abuse & Molestation Liability Hired & Non-Owned Auto Liability Participant Accident Medical Commercial Property Inland Marine Excess Liability

5. Participation Details

League / Team Liability

ⓘ The participation grid below is only applicable to League / Team Exposure. Leave blank if the insured does not operate a league or team program.

#	Sport / Activity Type	# Participants 12 & Under	# Participants 13–15	# Participants 16–18	# Participants Over 18
1
2
3
4
5
6

Camp / Clinic Liability

ⓘ The activity details grid below is only applicable to Camp / Clinic Exposure. Leave blank if the insured does not operate camps or clinics.

#	Participants Over 18?	Overnight?
1	Yes No	Yes No
2	Yes No	Yes No
3	Yes No	Yes No
4	Yes No	Yes No
5	Yes No	Yes No
6	Yes No	Yes No

Tournament / Event Liability (hosted)

ⓘ The activity details grid below is only applicable to Tournament / Event Exposure. Leave blank if the insured does not host tournaments or events.

#	Type of Event	Activity	Start Date	# of Days	Avg. Daily Participants
1
2
3
4
5
6

ⓘ Events with more than 5,000 spectators will trigger a referral for underwriter review.

6. Operations Profile

Organizational Structure

Years in Operation *

NGB / Association Affiliation

Is the organization affiliated with a National Governing Body (NGB) or state-level sports association?

Yes No

Venues & Facilities

Does the organization own or operate any facilities or fields?

Yes No – uses third-party venues

Does the organization use publicly-owned or municipality-owned fields / venues?

Yes No

Are written field / venue use agreements in place with all venues?

Yes No N/A

Ancillary Operations

Does the organization operate any overnight trips or travel team activities?

Yes No

Does the organization transport participants (minors or adults) in owned or third-party vehicles?

Yes No

Does the organization sell or serve alcohol at events?

Yes No

Does the organization operate concessions?

Yes No

Is an Additional Insured endorsement required?

Yes No

Additional Insured Name & Description (if yes, please complete the below)

7. Underwriting Supplemental

Prior Insurance

Current / Prior Carrier

Prior Policy Expiration Date

Prior Annual Premium

A. General

B. Waivers & Participant Releases N/A

C. Concussion / Traumatic Brain Injury (TBI) Protocol N/A

D. Coaching & Safety Standards N/A

E. Abuse & Molestation Controls N/A

F. High-Contact Sport Supplemental (if applicable) N/A

Complete this section if the organization offers youth tackle football, wrestling, or other high-contact sports per the underwriting guidelines.

For youth tackle football: Are all coaches certified? Is Accident Medical in force? Are concussion/TBI protocols documented?

All in place Partial N/A

For youth wrestling: Are certified coaches in place and concussion/TBI protocols documented?

Yes No N/A

Additional Details

G. Ineligible Exposures Declaration

The applicant must review the following ineligible sports and categories. By checking the box below, the applicant confirms that none of these exposures apply to their operations.

Ineligible Sports

Biking (Extreme)
BMX
Boating / Fishing
Boxing
Bungee Jumping
Cheerleading (Level III+)
Equestrian
Football – Tackle
Gymnastics
Horse Polo
Ice Hockey w/ Checking
Inline Skating
Jai Alai
MMA
Rodeo / Bull Riding
Roller Derby
Rugby
Skateboarding
Skiing / Snowboarding
Sports w/ Fighting / Weapons
Wakeboarding
Waterskiing
Windsurfing

Ineligible Categories

National Governing Bodies
State Soccer Associations
Large Regional / National Clubs
National Camp Organizations
Arenas / Stadiums (5,000+ seats)
Axe-Throwing Facilities
Bike Parks
Bowling Alleys
Boxing Gyms
Climbing Wall Facilities
Cross-Fit
Demolition Derbies
Driving Ranges
Escape Rooms
Facilities w/ Full Restaurant / Liquor
Family Entertainment Centers
Gymnastics Facilities
Health Clubs / Box Gyms
Ice Rinks
Inflatables
Intercollegiate Sports
Mud Runs
Obstacle Courses
Paintball
Professional / Semi-Pro Sports
Residential Sports Academies
Roller Skating Rinks
Scottish Games
Skate Parks
Sky Diving
Soap-Box Derbies
Spartan Races
Strong Man Events
Trampoline Parks
Zip Lines

I confirm that the applicant does not participate in, operate, or have any involvement with any of the ineligible sports or categories listed above.

8. Additional Named Insured

Complete if any additional entities require named insured status. Attach a schedule if more than one.

Name

Description of Operations

Ownership / Affiliation %

Address

9. Supporting Documents

Please send the following along with this completed application back to your underwriter. Loss runs are required — everything else is greatly appreciated if you have it available at this time. The more we have upfront, the smoother the process!

Required

4-year loss runs dated within 3 months of the proposed effective date

Also Appreciated — Please Include Any of the Following if Available

Sample participant waiver / release form
Concussion / TBI policy or CDC Return-to-Play acknowledgment
Background check policy (if Abuse & Molestation coverage is requested)
Participant roster with sport and age group breakdown
Venue or field use agreements
Organizational bylaws or charter (new ventures)
ACORD 126 / GL supplement

Additional Notes for Underwriter

10. Fraud Warning & Declaration

⚠ NOTICE TO POLICYHOLDERS — FRAUD NOTICE (NTC FR01 10/21)

NOTICE TO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime, and may subject such person to criminal and civil penalties.

NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND, AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO CALIFORNIA APPLICANTS: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO KANSAS APPLICANTS: Any person who knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance that such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

FIRE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of a fraudulent act, which may be a crime, and may subject such person to criminal and civil penalties.

NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE. The undersigned authorized representative affirms that all information provided is accurate and complete to the best of their knowledge. I understand that coverage is not bound until confirmed in writing by LIO Insurance.

11. Signatures

Applicant / Authorized Representative

Applicant / Authorized Representative Name

Title

Applicant Signature

Signature

Date

Producer / Broker

Producer Name

License Number

Producer Signature

Signature

Date