Coaches and Guides Form

First Name *

Last Name *

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Company Name

Expiry of Existing Policy or Desired Effective Date *

Please provide a full breakdown of business operations: *

Annual Gross Revenue *

Please breakdown % of Annual revenue per operation *

Years in Operation *

Please provide the names of all certified Instructors *

Date of Birth of Instructors *

Are you certified by a safety instructor group? *

If other, please provide details *

If not, please provide details on your certification *

How long have you been a safety instructor? *

Are you first Aid certified? *YesNo

Please provide details

What is your normal operating season for safety training courses? *

How long are your training courses? *

Do you supply participants with equipment? *YesNo

Please provide details *

Are participants required to wear approved bicycle helmets? *YesNo

Are you responsible for the setup of the safety training site? *YesNo

What is the minimum age of participants? *

If a client is under the age of majority are they accompanied by a parent or guardian? *YesNo

How many courses do you offer per year? *

What is the maximum number of participants per course? *

What is your instructor/participant ratio? *

What communication devices do you use while training? *

What is the address of where you provide your training or does the location change frequently? *

Are there any bodies of water on the property in which you offer your courses? *YesNo

Do you require signed waivers? *YesNo

Do you have non-certified support staff? If so, how many? *

Amount of CGL requested *

Amount of Professional Liability requested? *

Deductible Requested *

Property/Stock Limit Requested *

Would you like Cyber Insurance *YesNo

Has the business been involved in any claims in the last 5 years? *YesNo

If yes, please provide a description, including dollar amount paid or held in reserve? *

Has the applicant ever been declined or cancelled by an insurance company? *YesNo

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