Trip Cancellation Insurance • Cross Current Insurance

Your Details

Business Legal Name*

Lodge name*

Owner's Name & Title

Applicant's Name & Title*

Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone

Address of Lodge*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Season Dates

From	To

Underwriting Information

Prior year month by month (in season) gross revenue

Number of guests

Projected revenue for current season

Number of guests

Rates for upcoming season

Adverse Weather

Can trips continue in moderate rainfall and wind speeds up to 30 mph/50 kmh?

Yes
No

(Note: We are working on defining “moderate rainfall” and other adverse weather criteria that triggers coverage for Trip Cancellation. This section will be further expanded. Working with the underwriter.)

Does the lodge location have any history of flooding?

Yes
No

Claims Experience

Did you experience any cancellations in the last 3 seasons due to weather or other natural causes?

Yes
No

If yes, please explain

Additional Information

Number of Guides

Guide Details

Name	Date of birth

Number of Boats with Horsepower

Signature

DISCLAIMER

The coverage information contained in this questionnaire is only a general description and is not a statement of contract. In the event of a claim, any coverage provided by the insurer is subject to Terms, Conditions and Exclusions in the actual policy.

INSURANCE FRAUD NOTICE STATEMENT

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, commits a fraudulent insurance act which is a crime and may subject such person to criminal and civil penalties.

The undersigned states that he/she is the Applicant or is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief that the statements set forth in this application are true and complete and may be relied upon by the insurance company in quoting and issuing the policy.

Signature