Recreation Nova Scotia: Application for Liability Insurance

Organization:(*)

Invalid Input

Mailing Address:(*)

Please type your organization.

City:(*)

Please type your last name.

Province:(*)

Invalid Input

Postal Code:(*)

Invalid Input

Contact Person:(*)

Please type your first name.

Telephone Number (Work):(*)

Invalid Input

Telephone Number (Home):

Invalid Input

Fax Number:

Invalid Input

Email:(*)

Invalid email address.

In Operation Since:(*)

Invalid Input

Annual Operating Budget / Revenue:(*)

Invalid Input

Applicant Organization is Provincial / Regional / Other (if Other, please describe):(*)

Provincial

Regional

Other

Invalid Input

If Other - Specify:

Invalid Input

Non-profit:(*)

Yes

No

Invalid Input

Describe all activities and sports to be insured:

Invalid Input

Number of Participants:

Invalid Input

Estimated Number of Volunteers:

Invalid Input

Number of Paid Coaches / Managers:

Invalid Input

Number of Volunteer Coaches / Managers:

Invalid Input

Number of Officials / Referees:

Invalid Input

Number of Directors / Board Members:

Invalid Input

Total number of members in association (including participants, coaches, etc.):

Invalid Input

Do you receive & document police checks on all employees, coaches & volunteers:(*)

Yes

No

Invalid Input

If you do not obtain policy checks, explain:

Invalid Input

Appropriate operational procedures are required to eliminate abuse potential. Do you have a formal written policy including physical, sexual & mental abuse for your employees, coaches & volunteers?(*)

Yes

No

Invalid Input

Are your employees, coaches & volunteers made aware of the procedures/incident reporting for sexual abuse / harassment?

Yes

No

Invalid Input

Do you have written procedures for handling suggestions or complaints regarding any form of abuse?(*)

Yes

No

Invalid Input

Describe medical, first aid, safety and security procedures:

Invalid Input

Does the organization rent, lease / maintain a building or property?

Yes

No

Invalid Input

Describe all facilities and properties that the organization uses and / or maintains:

Invalid Input

Describe all facilities and properties that the organization uses and / or maintains, including the nature and frequency of use.

Invalid Input

Does the organization own or use motor vehicles? Describe:

Invalid Input

Does the organization own or use watercraft? Describe:

Invalid Input

Does the organization own any playground equipment?

Yes

No

Invalid Input

If so, describe the equipment and provide full details of the maintenance program in place:

Invalid Input

Does the organization require Board liability insurance? (Directors & Officers Insurance):

Yes

No

Invalid Input

Describe all fundraising activities for which insurance is required (e.g. social events, fundraising activities, other):

Invalid Input

Is alcohol served or available at any of your events?(*)

Yes

No

Invalid Input

If so, describe those events, specifying dates and name of the liquor permit holder.

Invalid Input

Click Check Box(*)

Invalid Input