Health Club Insurance Questionnaire - Inclusive

HEALTH CLUB INSURANCE QUESTIONNAIRE - INCLUSIVE

• NOTE: This questionnaire is to be submitted along with the following completed forms:
• ACORD Applicant Information application 125
• ACORD Commercial General Liability Section 126
• ACORD Applications for other requested coverages: Property; Garage; Crime; Inland Marine; Transportation; Excess Liability; Employment Related Practices.

GENERAL INFORMATION
1. Name of Insured (Applicant):
2. What is the insured’s FEIN number?
3. What is the insured’s website address?
4. Number of years in business?
5. Have you had more than $7,500 of total claims in the last three years? / Yes No
6. Total Annual Revenue:
Membership:
Initiation Fees:
Snack/Juice Bar:
Pro Shop Sales:
Restaurant:
Tanning:
Percentage of revenue from classes/seminars:
UNDERWRITING INFORMATION
7. What is the minimum age requirement to use club facilities?
Are minors (14 and under) permitted to take organized classes? / Yes No
If so, what is the student to teacher ratio?
8. Are minors required to be accompanied by parent or guardian? / Yes No
9. Do you have care, custody and control of minors? Yes No
Do you want Abuse and Molestation coverage? Yes No
(See below)
10. Is a Waiver/Hold Harmless signed by every member or guest? / Yes No
11. Is a Waiver/Hold Harmless signed by the parent or guardian for minor participants? / Yes No
12. Is a new waiver signed every year, or at membership renewal? / Yes No
13. Is club staffed during all hours that the club is opened? / Yes No
14. Please indicate exposures below:
Circuit Training / Cardio Equipment / Free Weights / Aerobic Mini Trampoline
Racquetball Courts / Handball Courts
Tennis Courts (Indoor / Outdoor) please circle which applies / Whirlpools
Steamrooms / Jacuzzis
Cold Plunge / Masseur / Masseuse
Tanning Units / DietCenter / Weight Control Services
Nursery / Babysitting / Aerobics / Step Aerobics
Running Tracks / Boxing / Kick Boxing
Martial Arts / Pro Shop
Swimming Pool(see below) / CampPrograms
Snack / Juice Bar / Other
Inflatables – Supplemental App. required / Rock Wall – Supplemental App. required
15. Are there batting cages on the premises? Yes No
If yes, are they coin operated or instructor fed?
How many batting cages are on the premises?
16. Do you have toning tables on the premises? Yes No
If yes, what is the age of each table?
17. Are there any beauty parlors on the premises? Yes No
18. Are there showers on the premises? Yes No
If yes, do they have a non-skid surface? Yes No
Is there a daily maintenance log? Yes No
19. Do you have cooking surfaces on site? Yes No
If yes, are cooking surfaces properly protected from fire exposures? Yes No
What type of food is prepared?
20. Are you a CrossFit facility? / Yes No
21. Are all personnel (including instructors and trainers) your employees? / Yes No
If no, please list those who are not and whether they carry their own insurance:
Name: / Yes No Limit:
Name: / Yes No Limit:
22. How many employees do you have?
23. How many of your employees are certified in CPR? First Aid?
24. What certifications do your trainers/instructors have?
25. Does the facility have an Automated External Defibrillator (AED)? Yes No
26. Does your state require you to make available an AED? Yes No
27. Is the AED easily accessible for those who have been trained in the use of the AED? Yes No
28. Do you have AED trained staff on duty during open hours? Yes No
29. Are employee references checked prior to hiring? Yes No
30. How often is equipment inspected, maintained?
31. Are maintenance logs maintained?
32. Who repairs equipment?
33. Is signage used throughout facility to indicate proper use of equipment, club features, and off-limits areas? Yes No
34. Are there GFI protectors on all outlets in the locker/shower/wet areas? Yes No
35. What type of aerobics floor is used?
ABUSE AND MOLESTATION
1. Do your employees and volunteers (paid and volunteer) employment application include questions about whether the
individual has ever been convicted for any crime, including sex-related or child-abuse offenses? Yes No
If yes, what is the process for dealing with a "yes" answer?
2. (a)Does your state permit you to do criminal background checks on:
Yes No Employees?
Yes NoVolunteers?
(b)If yes, do you routinely request and receive such background information on all individuals who will have contact with minors? Yes No
3. (a)Do you verify employment-related references for employees? Yes No
(b)Do you verify employment-related references for volunteers? Yes No
4. (a)Do you conduct a personal interview for employees? Yes No
(b)Do you conduct a personal interview for volunteers? Yes No
5. Do you have a written set of procedures for screening employees and volunteers? Yes No
If yes, please forward. If no, please describe your screening process.
6. Do you have an Abuse / Molestation Policy with regard to sexual abuse? Yes No
If yes, please indicate how it is transmitted to your employees/volunteers.
7. Do you have written procedures for dealing with allegations of sexual abuse? Yes No
If yes, please forward. If no, please describe what your current response would be.
8. Describe how your organization supervises employees and volunteers having custody of children.
Describe specific policy regarding any overnight travel.
9. (a) Has your organization ever had an incident which resulted in an allegation of sexual abuse? Yes No
If yes, please describe your organization's response to the allegation.
(b) Was a claim made against the organization or an individual within the organization? Yes No
When did the alleged incident(s) occur?
(c) Was the case taken to trial? Yes No / Civil Criminal
(d) What was the disposition of the case?
10. Regarding coverage for abuse and molestation, does your current insurance program:
Yes NoExclude coverage?
Yes NoLimit coverage (please forward a copy of the endorsement)?
Yes NoNeither exclude or limit coverage?
11. Please indicate age range of minors in your care or under the supervision of your employees or volunteers at any time.
12. Please describe your current and/or planned operations that involve the custodial care of minors.
NON-OWNED AND HIRED AUTO (NOHA)
1.Does the Insured have any owned automobiles? Yes No
If yes, who is the insurer?
Limits of coverage: / Effective date of coverage:

1. Do you allow employees to use their own personal vehicles for your business purposes? Yes No

If yes, how many employees use their own personal vehicles?
If yes, how often? Daily Weekly Monthly Other
Do you have a driver screening program for those employees who use their own personal vehicles for your business purposes? Yes No
Do you obtain Motor Vehicle Reports? Yes No
If yes, how often? Annually Every other year Other
Do you confirm that all employees who regularly use their cars for business purposes carry minimum personal auto limits? Yes No
If yes, what minimum limits are required?

1. Please provide the approximate cost of hire for all hired or leased autos during the course of the policy

period: $

1. Do you have a driver training program for employees who use owned vehicles or their own personal vehicles?

Yes No
5.Is hired auto physical damage required? Yes No
If yes, what is the maximum value of hired vehicle you would like insured? $
What deductible level would you like? $1,000 $2,500
SWIMMING POOL
1.What year was the swimming pool installed?
Do the pools/spas comply with the mandatory provision of the Federal Pool and Spa
Safety Act? Yes No
Are there diving boards? Yes No
If no, are NO DIVING signs posted on pool walls and decking? Yes No
Is the pool completely fenced and locked when not in use? Yes No
Are there lifeguards present at all times when the pool is open to the public? Yes No
If no, how is the pool area monitored?
How often is the water quality of the pool tested?
Hourly Every other hour Twice a day Daily Other:
Are testing logs kept? Yes No
Are there whirlpools/hot tubs? Yes No
If yes, how many?
If yes, is there an age restriction for use of the hot tub? Yes No
Are there proper ground fault interrupters in place for all swimming areas? Yes No
2.What is the maximum depth of the pool:
Are there clearly visible depth markers on the edging of the pool? Yes No
Is there pool lighting present and functioning? Yes No
3.Name or title of person in charge of pool operation and maintenance.
Is he/she AFO or CPO certified? / Yes No
ADDITIONAL INFORMATION NEEDED

• Need hard copy loss runs for the past 5 years

• Need a copy of the adult and minor Waiver and Release of Liability/Assumption of Risk

• Copy of Membership Application

• Medical Disclosure Form

• Inventory List consisting of values and serial numbers if property is to be written

I hereby represent and confirm that I have read all of the questions and answers contained herein and that, to the best of my knowledge, the information is true and correct.

I further acknowledge that I understand that this information is provided in conjunction with and in addition to the ACORD application(s) referenced above and that the information contained herein is subject to the same notices, disclaimers, warranties, and representations as on the referenced application(s).

DateSignature of Insured or Authorized RepresentativeTitle

Send completed form to: American Specialty Insurance & Risk Services, Inc.

7609 W. Jefferson Boulevard, Suite 100

Fort Wayne, IN 46804

Phone:(800) 245-2744

E-mail:

FORM NO. HEALTHCLUBSUPP.INCLUSIVE (03/17)Page 1 of 5SP # 7414679

American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved.