Climbing Guides Insurance Quote Form

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Climbing Guides Liability Quote Form

-   The "ENTER" or "RETURN" Key will submit the application.   Use the "TAB" Key and Mouse to navigate.
      If application is submitted by mistake, use the "BACK" Button on your browser to return to the application.

-   Allow 2 weeks to receive a quotation (LEAVING QUESTIONS BLANK WILL DELAY PROCESSING)
-   Available in all States

GENERAL INFORMATION

Legal Business Name:		Phone: This # isCell Biz Home
D/B/A Name:		Contact:
Mailing Address:		Fax:
City:	State: Zip:	Email:
County:	(NOT Country)	Website: www.
Type of Entity:	Corp Partnrshp Sole Prop Other:	Quote Need by Date: Two (2) weeks is normal lead time.
Year Business Established:	Years Experience in Field:	Federal ID #:

List All Owner(s) / Officer(s) Names:

Trade Associations you Belong to:
AMGA AAC AO Other:

Brief Description of Operations: (If a new business, please describe prior experience also)

-Additional Space is available below in Comments Section.

Operations Physical Address you OWN or LEASE (list all):                   Description (ie: Base, Office, Store, Storage, Etc)
1.
2.

POLICY INFORMATION (Why we want to know)

Have you, or anyone else in your company, completed other insurance applications to obtain quotes either in writing or over the phone? Yes No

What is your current "Per Occurrence" Liability Limit, or What limit do you need?

Who is your current Insurance "Company" (not your Agent): OR This is a New Business (SEE NEXT)

FOR A NEW BUSINESS: Briefly describe your experience in your field of outfitting, and also any business related experience you have.
An Example is given (CLICK HERE for pop up) which outlines what type of details are needed.

If you have a policy in place, please answer following:
Expiration Date: Current Premium: Target Premium:(a competitive quote would be this)

GENERAL LIABILITY RATING INFORMATION

TYPE OF OPERATIONS	RATING INFORMATION FOR EACH OPERATION	GROSS SALES PER YEAR
CLIMBING (CLUBS)	Number of Members:
CLIMBING WALLS (Stationary)	# of Walls: Estimated # of Participants:
CLIMBING WALLS (Portable)	# of Walls: Estimated # of Participants:
OUTDOOR ROCK CLIMBING	Estimated # of Participants:
COMPETITION CLIMBING EVENTS	Estimated # of Participants: Estimated # of Events:
RETAIL SALES	Description of Retail Items Sold:
LODGING / CAMPING Your Owned Units/Sites Only		GROSS SALES PER YEAR
LODGING STRUCTURES (Owned)	# of Lodging Structures Owned: Total sleeping capacity (all owned structures):	or Check if Incl in Trip Price
CAMPGROUND - RV / TENT SITES (Owned)	# of Camp RV / Tent Sites Owned: Total sleeping capacity (all Sites):	or Check if Incl in Trip Price
OTHER OPERATIONS Not Listed Above		GROSS SALES PER YEAR
OTHER:	Estimated # of Participants:
OTHER:	Estimated # of Participants:
YES, estimated # of Customers and Sales have been entered above for our operations, If they were not entered we will not be able to quote so please provide an explanation in the comments at the bottom of the form

SUPPLEMENTAL INFORMATION
- leaving questions blank will delay quote -

GENERAL INFORMATION

Are all operations you provide listed in above rating section? Y N If NO, please explain in comments section (bottom form).

What is your normal operating season? (month) to (month) or Full Year

Please check what type of food, beverage service you have? Snacks Breakfast Lunch Dinner

Do you sell or offer alcoholic beverages?	Y N	Is a signed Waiver / Release / Assumption of Risk form obtained from all customers?	Y N
What % of trips / operations are overnight or multi-days? Enter "0" if none	%	Does a responsible adult sign for all minors?	Y N
If overnight operations, what % is open tent camping?	% N/A	How many certificates of insurance do you normally need each year?
What is the minimum age of participants?		Any use of animals (horses, dogs, mules,etc.)?	Y N
How many employees do you have?	Full Time Part Time
What percentage of your operation is on:	Wilderness Land Leased Land Forest Svc Land BLM Land
FOREIGN OPERATIONS Any operations conducted outside the U.S? No, SKIP Next #1-5 Questions. If YES, Complete Next #1-5 Questions 1. Describe foreign operations activities? 2. What countries are you operating in? 3. Do your employees guide the trips, or are the trips subcontracted? Please elaborate: 4. How much annual sales are generated from these trips? 5. Were these sales figures included in the above General Liability Rating SectionYes orNo they are in addition to above sales

SAFETY EQUIPMENT & PROCEDURES

Which of the following is taken on each trip?First Aid Kit Flares Radios Cell Phones Satellite Phones Snake Bite Kit Heart Defibrillator Oxygen

Is a safety speech given to participants prior to all trips explaining the hazards of your operations, and the proper use of all equipment?Y N

Is a short training program, or course, used to determine the customers ability using your equipment?Y N

Do you file your itinerary plan with?Local Authorities Co-Workers Not on Trip Responsible 3rd Party Do Not File

GUIDES / OWNERS Questions (Guided Trips / Instruction)
NOT APPLICABLE - No Guides Used & Owners Do Not Guide
NOTE: If you have no employed guides, but you guide as an Owner, complete this section pertaining to your information.

Are new guide\\'s references check?	Y N	Are all guides qualified in CPR by the American Red Cross or American Heart Association?	Y N
Is there a guide training program in place?	Y N	Have all guides completed 1st Aid Training?	Y N
Do you subcontract any trips or guided services?	Y N	Does one guide per trip carry an Advanced First Aid Card or Wilderness EMT?	Y N
What is average Guide to Customer ratio?		Are any of your guides working as "Independent Contractors"? Click HERE for definition.	Y N
If a State or Government Authority requires guides have guide licensing, are your guides licensed? Y N Not Required
Any employees under age of 18? No Yes, what are their duties?
NAME OF GUIDE (Include Owners)	AGE	QUALIFICATIONS (1st Aid, CPR, WFR, PCGI, EMT, AMGA Member, etc)	YEARS EXPERIENCE






Total # of Guides? If more than six guides, we can obtain a full guide list at a later time or HERE is a link to a fillable guide schedule which shows the information needed. This can be faxed 877-271-8898 or emailed insurance@thompsongusic.com

CLIMBING QUESTIONS

Briefly describe where you operate?

What is the maximum # of climbers at any one time on a trip?

Please check all operations that are applicable: Bouldering   Climbing Walls (stationary)   Climbing Walls (portable)
Ice Climbing Top Rope Climbing Lead Rope Climbing Ski Mountaineering   Rappelling
      List all Other

What % of your climbing operations are unguided (customers are left to climb on their own)? Enter "0" if NONE

Are Helmets offered as part of your trip or activity? Yes No

Are Helmets required as part of your trip or activity? Yes No

What is the minimum age of participants accepted? If needed, further explanation:

What is the maximum height of a climb? If needed, further explanation:

Do your guided trips include camping overnight? Yes No

Do your trips include some type of hiking along with the climbing? Yes No

Is helicopter evacuation / medivac available in all your climbing areas? Yes No Further Expl:

LOSS INFORMATION
Enter all reported liability claims for the past four (4) years, or check "NO CLAIMS" below.

Date of Loss	NO CLAIMS PAST FOUR (4) YEARS or complete below Description of Loss	Amount Paid

The above information is correct to the best of my knowledge. Check: Initials:
If Enter Button was pressed (Enter Button Submits the Form), use "Tab" key or Mouse to navigate. Submit Button is at bottom.

ADDITIONAL COMMENTS / INFORMATION

WOULD ALSO LIKE A QUOTE FOR:
   PROPERTY - Quote Form is available on our site. "PROPERTY" Quote Form
   AUTO - Quote Form is available on our site. "COMMERCIAL AUTO" Quote Form
   UMBRELLA

To Help us route / expedite your submission to the correct person in our office (if applicable):
If you were referred to us, please tell us what company or person referred you:
If you spoke to someone in our office, please tell us who:

Final Item: Most companies will require a copy of your waiver / release / assumption of risk form to quote. This can be delivered to us via:
   - FAX to:      (877) 271-8898
   - EMAIL to:   insurance@thompsongusic.com
   - MAIL to:     Address at bottom
___________________________________________________________________
    Copy of your current Waiver, Release of Liability, or Assumption of Risk Form
          Sample Waiver is HERE (MS Word Doc - Click "CANCEL" for Authorization pop-up).
              This item will be:    Faxed      Emailed     Mailed

QUESTIONS / HELP	Call our staff and ask for help for an Outfitters Quote, or filling out our Online Quote Form. Thompson - Gusic Insurance Group 4067 Greensburg Pike Pittsburgh PA 15221
Email:	insurance@thompsongusic.com
Phone:	(412) 271-8888 (9 - 4:30 EST)
Fax:	(877) 271-8898