David L. Murphy Insurance

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Insured Name:
Address:
City, State, Zip:
Contact Person:
Phone Number:
Email:
Website:
May we email all correspondence including policies/certificates? Yes No
For Profit Individual Partnership Corporation Non-Profit Other
Years this entity in business: Years experience of this owner:
Underlying Medical Accident Limits Carried: $25,000 $100,000 $1,000,000
Limits of Liability: $1,000,000 Each Occurrence, $3,000,000 Aggregate
Effective Date Requested:

General Information

1.	Have any of your policies or coverage's been declined, canceled, or non-renewed during the past 3 years? If yes, explain below.	Yes No
2.	Does the league or camp require a completed waiver from all participants?	Yes No
3.	Is parent's signature required for minors?	Yes No
4.	Do you have a written incident report procedure in place?	Yes No
5.	Do you keep a log of all incidents?	Yes No
6.	Are you or your staff trained/certified in CPR or First Aid?	Yes No
7.	Are any of your coaches, managers, trainers, officials, referees, statisticians or scorekeepers independent contractors that are paid a fee for their services ?	Yes No
8.	Do you require player's to wear helmets?	Yes No
9.	Has the applicant incurred any prior losses? If yes, explain below.	Yes No
Explanations:

Combined Liability and Accident Premium Calculation

League:	Number of Youth:	Rater per Participant:	Total:
	Number of Adult:	Rate per Participant:	Total:

Camps:	Total number of Youth camper days:	Rate per day:	Total:
	Total number of Adult camper days:	Rate per day:	Total:
Please attach a schedule of the camps and participants if necessary: Additional Insured Information (please include name, complete address and relationship) Waiver and Release System Requirement You must maintain a system to regularly secure signed Waiver and Release forms from participants allowed to enter restricted areas and to prevent restricted area credentials from being issued before participants have properly signed and executed the Waiver and Release forms. For minor participants (under eighteen [18] years of age), you must always maintain a system to secure valid Minor Waiver and Release forms signed by the parent or legal guardian. Unintentional error on your part in securing Waiver and Release or Minor Waiver and Release forms will not void your coverage in the event of an "occurrence" to a participant. However, your failure to maintain an adequate system to regularly secure Waiver and Release or Minor Waiver and Release forms will void your coverage in the event of an "occurrence" to the participant. When you notify us of an "occurrence" involving a participant, you will also provide us with a valid Waiver and Release form that has been signed and dated by the participant prior to the time of the "occurrence". If the participant is a minor (under eighteen [18] years of age), you will provide us with a valid Minor Waiver and Release form that has been signed by the parent(s) or legal guardian(s) of the minor participant. Applicant's Statement and Declarations The applicant declares to the best of his/her knowledge the information contained in this application and all supplements attached to be true and that no material facts have been suppressed or misstated. The applicant further understands that any false or fraudulent statements or misrepresentations could result in termination or voidance of any insurance contract issued from the information stated herein. Applicant Signature: checking Yes will satisfy a signature requirement Yes No PLEASE NOTE: You must check either YES or NO above, or the form will automatically reset if you try to submit it.

David L. Murphy Insurance Agency, Inc.
10 Liberty Street, Danvers, MA 01923
Phone: 978-777-5930