LIO Facilities 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)

DBA / Facility Name

Primary Contact

Phone

Email Address

Website

Mailing Address

Street Address

Street Address 2

City

State

Zip Code

3. Facility Location

Enter the primary facility location. If same as mailing address, check below. Add additional locations in Section 8.

Same as mailing address

Street Address

City

State

Zip Code

Total Facility Square Footage

Total Acreage (if outdoor)

Occupancy

Owned Leased

Hours of Operation

Year Facility Established

Indoor / Outdoor

Indoor Outdoor Both

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 (equipment) Excess Liability

5. Facility Profile & Operations

Facility Classification

ⓘ Select the primary facility type that best describes the dominant operations. If the facility supports more than one sport or activity, select the predominant programming.

If Other, Describe

Sports / Activities Hosted at Facility

Facility Usage

Does the facility host leagues operated by the applicant?

Yes No

Does the facility host third-party leagues, teams, or tournaments?

Yes No

Does the facility host events with greater than 500 attendees?

Yes No

Does the facility rent space to outside groups (private lessons, birthday parties, training sessions)?

Yes No

Revenue Composition

ⓘ Disclose all revenue sources accurately.

Revenue Source	Annual Revenue ($)	% of Total
Field / Court / Facility Rentals
League / Team / Membership Fees
Camps / Clinics / Lessons
Tournament / Event Hosting Fees
Birthday Parties / Private Events
Snack Bar / Concessions
Pro Shop / Merchandise / Apparel
Restaurant / Bar / Alcohol Sales
Spectator Admission / Gate Fees
Sponsorships / Advertising
Other Ancillary Services
TOTAL ANNUAL REVENUE *

6. Operations & Risk Controls

Organizational Background

Years in Operation *

Year Business Was Established

Years Owner/Director Experience

Staffing

# Full-Time Staff

# Part-Time Staff

# Seasonal Staff

# Independent Contractors

Are staff trained in CPR / AED / First Aid?

Yes No

Is someone certified in First Aid / CPR on site or immediately available whenever the facility is open?

Yes No

Are AED units available on-site?

Yes No

Facility & Safety

Does the facility conduct regular safety inspections of playing surfaces / courts / fields (logged)?

Yes No

Is equipment inspected and maintained on a regular schedule?

Yes No

Is there a written emergency action plan (medical, fire, severe weather)?

Yes No

Are spectator seating areas, walkways, and parking maintained and inspected (slip-trip-fall controls)?

Yes No

Are signed waivers / releases required for all participants, including private rentals and party guests?

Yes No

For minors under 18, are waivers signed by a parent or legal guardian?

Yes No N/A – No minors

Third-Party Risk Transfer

Are written facility-use agreements required for all third-party tenants / renters?

Yes No N/A

Are renters / tenants required to carry their own liability insurance and name the facility as Additional Insured?

Yes No N/A

Ancillary Operations

Does the facility operate any batting cages?

Yes No

Does the facility involve swimming, diving, or any open-water activities?

Yes No

Does the facility provide transportation for participants?

Yes No

Does the facility sell or serve alcohol on-premises?

Yes No

Does the facility operate concessions / snack bar?

Yes No

Does the facility operate a pro shop or sell merchandise / apparel?

Yes No

Does the facility host birthday parties or private events?

Yes No

Does the facility include inflatables, bounce houses, or similar amusement equipment?

Yes No

Is an Additional Insured endorsement required (e.g., landlord, municipality)?

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 / TBI Protocol N/A

Required for facilities hosting any sport where head-injury risk exists.

Has the facility adopted a formal concussion management program consistent with CDC "Return-to-Play" guidelines?

Yes No N/A

Are coaches, instructors, and staff trained to recognize signs of concussion?

Yes No N/A

Does the facility enforce a no same-day return-to-play policy for any athlete suspected of concussion?

Yes No N/A

D. Abuse & Molestation Controls N/A

E. Property & Building (if Property requested) N/A

F. Ineligible Exposures Declaration

The applicant must review the following ineligible facility types and operations and confirm none apply.

Ineligible Facility Types

Large Commercial "Box Gyms"
Trampoline / Rebound Facilities
Rock Climbing Gyms / Walls
Arcades / Family Entertainment
Bowling Alleys
MMA / Boxing Gyms / Fight Clubs
Stadiums / Arenas >5,000 Seats
Pools w/ Diving >3m, Hot Tubs, Saunas
Public / Municipal Pools
Waterparks / Splash Parks
Gymnastics Training Centers
Driving Ranges
Skate Parks / Skate Rinks
Bike Parks / BMX Tracks
Climbing Wall Facilities
Axe-Throwing Facilities
Escape Rooms
Facilities w/ Full Bar/Restaurant (>25% Rev)
"Eatertainment" Pickleball Venues
Demolition Derby / Motorsports
Residential Sports Academies
Cryotherapy / Recovery Studios
Physical Therapy Centers
SCUBA Training Facilities

Ineligible Sports / Activities

Tackle Football
Ice Hockey (w/ Checking)
Tackle Rugby
Boxing / MMA / Combat
Gymnastics (Training & Comp.)
Cheer Level III+
Wrestling (Unsanctioned)
Equestrian / Polo / Rodeo
Motorsports / Go-Karting
Wakeboarding / Waterskiing
Skiing / Snowboarding
BMX / Skateboarding
Skydiving / Bungee
Roller Derby
Diving >3m
Professional / Semi-Pro
Collegiate / Scholastic
Extreme / Adventure Races
Spartan / Mud Runs
Inflatables / Obstacle Courses

I confirm that the applicant does not operate or have any involvement with any of the ineligible facility types or sports listed above.

8. Additional Locations / Named Insureds

Complete if the applicant operates multiple facility locations or requires additional named insured entities. Attach a schedule if more than four.

#	Location / Entity Name	Address (Street, City, State, Zip)	Sq. Ft.	# Participants
1
2
3
4

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 / rental / party waiver & release form
Facility use / rental agreement template
Concussion / TBI policy or CDC Return-to-Play acknowledgment
Background check policy (if Abuse & Molestation coverage is requested)
Sample emergency action plan
Facility photos & site plan
Lease / occupancy agreement (if requesting Property)
SOV / Statement of Values (if Property is requested)
ACORD 125 & 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