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Insurance Sample Forms


The following are just some of the insurance forms that you would need to have taken care of and/or would relate to a business. These sample forms have been provided by (CWIC) Colorado Western Insurance Company and have reprinted with their permission. For further information, please contact your insurance agent.

What We Do... CWIC uses experience and the independent agency system to meet the needs of specialty lines that most insurance companies simply don't address. Utilizing expertise gained in calculating losses for businesses without a lot of actuarial data, the company is able to correctly price insurance for recreational businesses. By operating with general agents to market the business, CWIC effectively manages resources to provide a one to two-day turnaround on policy issuance and to cover unique, localized programs or events on an individual basis. CWIC personnel travel extensively to maintain close relationships with agents and stay attuned to market needs and trends. Operating as both Admitted and Excess and Surplus Lines in several states, and joining forces with Genesis Indemnity (an A++ rated company) to operate nationally, CWIC offers exceptional service for special risk industries.

Recreational Industry Program - CWIC's Recreation Industry program insures premises and rental operations for recreational businesses. Services cover businesses that rent or lease recreational sporting equipment; commercial equestrian boarding, training or breeding operations with or without auxiliary activities; as well as guides, outfitters and packers who provide guided outdoor recreational activities. A special application is required for this program that offers limits up to $1 million and a variety of adaptable features to cover small to large operations.

Program Features - The CWIC Recreation Industry program offers the following features to maintain the affordability and flexibility you need to meet your budget and adequately insure the safety of program participants: Limits up to $1,000,000 per occurrence; Medical payments of $5,000; Fire damage legal limit of $100,000; Products and completed operations; Personal injury and advertising injury; Physical damage to property in your care, custody or control; Defense costs outside the limits.

Optional Coverage’s - Limited assault and battery coverage; Hired or non-owned auto coverage and fire super session coverage for accidental fires started on government property

Eligible Activities and Coverage’s: hunting/fishing guides or tours, water rafters, trail rides/park trips, rope courses, mountaineering, climbing walls, hiking/biking tours, wagon/hay/sleigh or carriage rides, resorts, campgrounds, amusement centers, trap/skeet ranges, guest ranches, swimming pools, water parks, snowmobiling tours, ATV tours, kayak rental/tours, canoe rental/tours, paintball fields, family fun centers, go-kart tracks, batting cages, farriers, livestock auctions, mini-golf, driving ranges, boarding stable operations, pony rides, pleasure or show horses, ccc for horses, race horses, riding instruction, llama trekking, boat, jet ski or wave runner rental, ski/cross country ski rental/ snowboard rental, riding clubs, hunting clubs and bike rentals. Source: West Plains Insurance Inc.; Watford City, ND 701-842-2466

ACKNOWLEDGMENT OF RISKS - I understand and acknowledge that the activity that I am about to engage in bears certain known risks and unanticipated risks which could result in injury, death, or damage to myself, my property, or to other third parties. I understand and acknowledge those risks may result in personal claims against____________or claims against me by other third parties.

ACCEPTANCE OF RISK AND RESPONSIBILITY - Being aware that this activity entails risks of injury to me and to third parties as a result of my actions, I agree to accept and assume all responsibility and risk for injury, death, or damage to myself or to my property arising from my participation in this activity. I agree, covenant, and promise to accept and assume all responsibility and risk for injury, death, or damage to other third parties and their property arising from my participation in this activity. My participation in this activity is purely voluntary and I elect to participate in spite of the risks.

RELEASE - I hereby voluntarily release____________________, its agents or employees, and all other persons or entities from any and all liability, claims, demands, actions or rights of action, which are related to or are in any way connected with my participation in this activity, including specifically but not limited to the negligent acts or omissions of ________________________, its agents or employees, and all other persons or entities, for any and all injury, death, damage to myself or to my property. I further agree, promise, and covenant to hold harmless and indemnify _________________, its agents or employees, and all other persons or entities from all defense costs, including attorney’s fees, or from any other costs incurred in connection with claims for bodily injury or property damage which I many negligently or intentionally cause to other third parties in the course of my participation in the activity. I further agree, promise, and covenant not sue, assert or otherwise maintain or assert any claim against ________________, its agents or employees, and all other persons or entities, for any injury, death or damage to myself or to my property, arising from or connected with my participation in this activity or from any claim asserted against me by other third parties. In signing this document, I fully recognize that if anyone is hurt or property is damaged while I engage in this activity, I will have no right to make a claim or file a lawsuit against _________________, or its officers, agents, or employees, even if they or any of them negligently caused the bodily injury or property damage.

EFFECT OF THIS RELEASE AGREEMENT - I understand and acknowledge that by initiating and/or signing this document I have given up certain legal rights and/or possible claims which I might otherwise asset or maintain against _________________, its agents or employees, and other persons, entities, including specifically, but not limited to, rights arising from or claims for the acts or OMISSIONS, negligent in any degree, of _______________________________, its agents or employees, and all other persons or entities.

I understand and acknowledge that by initiating and/or signing this document, I have assumed responsibility and legal liability for the claims or other legal demands, including defense costs, which may be asserted by spectators or other third parties against me as a result of participation in this activity. I understand that this is the entire Agreement between myself and _______________, its agents or employees, or agent of ___ or by me. My signature below indicates that I have read this entire document, understand it completely, and agree to be bound by its terms.

SIGNATURE______________         SIGNATURE OF PARENT OR GUARDIAN (under 18)_____________________ ____

____________________________
(SAMPLE)
RELEASE   
In consideration of receiving permission from ________________________to enter upon the premises of their farm the receipt of which permission is hereby acknowledged and in further consideration of receiving permission to hunt as an individual legally licensed to hunt, pursue and take wild game under the laws of the State of South Dakota, the undersigned does hereby release and agree to hold harmless __________________________, and their agents and employees, (is any), from any and all liability claims, legal actions to lawsuits of any nature arising from or relating to any loss, damage of injury, including death or personal injury, that may be sustained by any of/or each of the undersigned while upon the premises of the farm or upon any property leased or under the control or supervision of said ______________, will not be held responsible for injury, damage or loss to persons or property occurring directly or indirectly by reason of negligence or wrongful acts of any member of the hunting party, guide, agent, or group representative.

Each of the undersigned acknowledge that they are fully aware of the risks inherent with and associated with hunting and pursuit of wild game and that the undersigned hereby elects voluntarily to enter on the farm and premises owned, controlled or leased by _______________________________.

Each of the undersigned specifically acknowledges that they are experienced hunters and are knowledgeable concerning safety rules and precautions to be taken when handling firearms, that they have hunted previously and recognize the fact that neither _____________make any representation as to the safety if the sport of hunting itself nor as to the qualifications or expertise other hunters included within the hunting party. Each of the undersigned hereby voluntarily assumes the risk of loss, damaged or injury including death that may be sustained by the undersigned while upon the _________premises while engaged in actual hunting and stocking of game and while being transported to or from hunting locations by motor vehicle or any other mode of transportation furnished by _____________________.

This release shall be binding upon the heir’s next of kin, executors, administrators and personal representatives of the undersigned. By signing this release each of the undersigned represent: (1) that he/she has read the foregoing release, understands it, and has entered into said release voluntarily. (2) That he/she is legally licensed to hunt wild game under the laws of the State of ______ and is an experienced hunter, and (3) that he/she has hunted previously and is in all respects qualified to hunt safely.

Dated this _______ day of _______________________20_____.

______________________________
Signature


(SAMPLE) PARTICIPANT RELEASE OF LIABILITY

-READ BEFORE SIGNING-

In consideration of being allowed to participate in any way in the _______________ (Name of Organization) program, related events and activities, the undersigned acknowledges, appreciates, and agrees that:  The risk of injury from the activities involved in these programs is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury to me does not exist; and I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASE'S, or others, and assume full responsibility for my participation; and, I willingly agree to comply with the stated and customary terms and conditions for participation.

If I observe any unusual significant concern in my readiness for participation and/or in the program itself, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,  I, for myself and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE THE_______________________, its officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event ("Releases'"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my involvement or participation in these programs.  WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I, for myself and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releases' from any and all liabilities incident to my involvement or participation in there programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND JUST SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Date: ___________________________     Signed: _____________Age:_________

PARTICIPANT SIGNATURE ----PRINT NAME:________________________________

NOTE: This is a SAMPLE WAIVER FORM only. Final wording should be as directed by the insured's counsel, but mostly observe the principles represented within the above.



(SAMPLE) OUTLAW TRAIL RIDES

Release of Liability

This Release is executed on the ____day of __________________, 20___by ____________
of_____________, known as Releasor, to OUTLAW TRAIL RIDES, of Hot Springs, South Dakota, known as Releasee.     
In lawful consideration of being permitted to ride a horse belonging to or in the care of Outlaw Trail Rides, in a supervised setting or otherwise, I, the Releasor, being of legal age, hereby agree that I, my heirs, distributes, guardians, legal representatives and assigns will not make a claim against, sue, attack the property of, or prosecute Outlaw Trail Rides, or any of its owners, employees or agents, either in law or in equity, arising from or by reason of any bodily injury or personal injuries known or unknown, death or property damage resulting or to result from any accident which may occur as a result of my use of any horse belonging to or in the care of Outlaw Trail Rides or any activities in connection with such use, whether occasioned by negligence or not.

I am aware that the use of such animals may constitute a hazardous activity, and am voluntarily participating in such activity with knowledge of the dangers involved and hereby agree to accept any and all risks of injury or death.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND OUTLAW TRAIL RIDES, ITS OWNERS, EMPLOYEES AND AGENTS, AND I HAVE SIGNED IT OF MY OWN FREE WILL.

OUTLAW TRAIL RIDES

By:_______________________________       By: ___________________________________
Releasor                                                                                                       Parent/Guardian

 

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