| Application Type: | New Application Renewal |
| Named Insured (Swim Club Name): | |
| Website Address: | |
| Entity Type: | |
| Contact Person: | |
| Name of Pool facility to be managed: | |
| Pool facility Address: | |
| City, State ZIP: | , |
| Cell Phone: | |
| Business Phone: | |
| Fax: | |
| E-Mail: | |
| Projected annual pool admission revenue: | |
| Actual pool admission revenue prior year: | |
| Please describe and give revenue projections for any other income producing operations you control (i.e. concessions, etc.): | |
| Is pool indoors or outdoors? | |
| Does the pool have diving boards or diving platforms? | |
| If yes, please describe how many, size of boards | |
| Please describe controls for use of diving facility: | |
| Does pool facility have a water slide? | |
| If yes, please describe and provide information regarding management controls on the public use of the slide: | |
| Does pool facility have a kiddie pool? | |
| If yes, please describe controls for use of the kiddie pool: | |
| Does the pool facility and your staffing of it meet or exceed all municipal codes and regulations for pool operations? | |
| Are you responsible for maintenance, chemicals, etc.? |
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| If Yes, describe duties, otherwise who is responsible?: | |
| Do they provide you with a Certificate of Insurance? | |
| Please describe your prior experience in pool management: | |
| How many lifeguards are employed? | |
| Please describe the minimum training and experience required of your lifeguards: | |
| Previous Loss History: | |
| Previous Carrier: | |
| Policy #: | |
| Does the pool owner have insurance on the facility? | |
| If yes, are you added as additional insured for THEIR negligence? | |
| Certificate Requests Additional Insured? | |
| Name: | |
| Attn: | |
| Address: | |
| City, State ZIP: | , |
If applicable, send a copy of the contract you have with the pool owner to RMS, in addition to this application.
Risk Management Services
PO Box 32712
Phoenix, AZ 85064-2712 |
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