or association the school is affiliated with: _____________________________ __________________________________________________________________________ Applicant's Signature: ________________________________________ Date: ________________ CQU 013 (06-97) Page # 2 Capitol Indemnity Corporation MARTIAL ARTS TOURNAMENT QUESTIONNAIRE Annual number of tournaments sponsored (if more than six, please use additional applications): Anticipated # Anticipated Date(s) Location of participants (Name,Street,City,State,Zip) 1.<br><br> ___________ ______________________________ __________ 2. ___________ ______________________________ __________ 3. ___________ ______________________________ __________ 4.<br><br> ___________ ______________________________ __________ 5. ___________ ______________________________ __________ 6. ___________ ______________________________ __________ 2) Does the school require a signed Hold Harmless agreement from participants?<br><br> ¨ Yes ¨ No (If "Yes", please attach a sample copy of the form used.) 3) Events contemplated at all Tournaments ¨ Free Sparring ¨ Forms (Kata, etc.) ¨ Weapons forms ¨ Breaking ¨ Demonstration ¨ Other ____________ (describe) * This policy does not provide coverage for any claim, suit or cause of action arising out of any injury to the head of a contestant actively engaged in free sparring, unless at the moment such injury takes place, the injured contestant and his/her opponent are wearing approved protective headgear, padded kicking boots, and dental protective devices (mouthpiece), I HEREBY DECLARE TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT ALL OF THE FOREGOING STATEMENTS ARE COMPLETE AND TRUE AND THAT THESE STATEMENTS ARE OFFERED AS AN INDUCEMENT TO THE COMPANY TO ISSUE THE POLICY FOR WHICH I AM APPLYING. IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THE QUESTIONNAIRE DOES NOT BIND THE INSURANCE COMPANY Applicant's Signature: ____________________________________________ Date: ____________ Producer's Signature: ____________________________________________ Date: ____________

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