Heritage General Agency, Inc.
9250 E Costilla Avenue www.heritagega.com 303/290-6445
Suite 650 Fax 303/290-0285
Englewood, CO 80112 Wats 1/800-548-7816
GUIDES OR OUTFITTERS QUESTIONNAIRE
(Please attach to a completed General Liability application)
1. Name of Applicant: ____________________________________________________
2. License or permit used by: _______________________________________________
3. Annual gross sales: $ ____________________________________________________
4. List age and years of experience for all guides: ________________________________
______________________________________________________________________
______________________________________________________________________
5. Nature of guided operations:
Hunting Cross Country Skiing Cabins
Fishing Bicycle Touring ATVs (any use of)
Backpacking Other (Describe)
6. Geographical location of preserve, lakes, rivers, streams, wilderness or trails used: ___
______________________________________________________________________
7. Equipment provided to client(s):
Rifles or Shotguns Cross Country Skis
Fishing Tackle Bicycles Number in use: ___________
Backpacking Gear Canoes, Rowboats, Rafts Number in use: ___________
Other (Describe) _____________________________________________________
8. Horses/mules provided to client(s):
Saddle Number in use: ___________
Pack Number is use: ___________
9. Please attach a copy of the release for client(s) to sign.
10. Any boats rented without a guide? Yes No
Number of boats, total horsepower of each:
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11. Safty Equipment:
Are Coast Guard Approved Life Jackets Used? Yes No
Are boats radio equipped? Yes No Cary Signal Panels? Yes No
Emergency Signal Mirrors? Yes No Aircraft fly-over surveillance? Yes No
Describe first aid equpment carried:
12. Estimated Guest Days (ex: 1 guest for 7 days = 7 guest days):
13. Total Annual receipts: $
14. Previous Carrier: Policy Number:
Premium:
Previous Loss (describe each):
15. Do you have an outfitters license?
16. Certificates of insurance for:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the
information contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the
purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable
from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or officer)
PRODUCER’S SIGNATURE: DATE:
AGENT’S NAME:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
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WHI 21-0370 (03/99)