Trade Name of Business:

E-MAIL Address:

Legal Name of operating Entity:

Street Address of Club

City, State, & Zip
  

Phone Number

Contact Person

Number of Years in Business

Estimated Annual Gross Sales

Number of Members

Sales from membership dues

Sales from Pro Shop

Sales from Snack or Concessions

Name of Current Insurance Company and expiration date

Current Annual Premiums (Optional)

Coverages Currently Carried:
Property
General Liability
Loss of Income
Money and Securities
Work Comp
Commercial Auto
Commercial Umbrella

List any of the above coverages
which are not currently provided, but desired

Claims History - List details of all claims in the last three years.

Details of Operations (Check Those Which Apply)

Restaurant or Lounge  Yes   No
   (If yes, please call, additonal questionnaire required.)

Professional Trainers  Yes   No

Team Sports Yes   No

Dances Yes   No

Run, Walk, or Bike Competitions Yes   No

Massage Therapy Yes   No

Martial Arts Classes Yes   No

Day Care Yes   No
   (If yes, please call, additonal questionnaire required.)

Gymnastics Yes   No

Handball & Squash Yes   No
   Number of Courts

Tennis Yes   No
   Number of Courts

Basketball Yes   No
   Number of Courts

Volleyball Yes   No
   Number of Courts

Swimming Pools Yes   No
   Number of Pools

Weight Machines Yes   No

Free Weights Yes   No

Aerobic Equipment Yes   No

Saunas Yes   No

Steam Rooms Yes   No

Tanning Beds Yes   No
   (If yes, please call, additonal questionnaire required.)

Whirlpool Yes   No

If there is a pool:

• Is there a diving board? Yes   No
  If yes, Height:
  
• Are Depths marked? Yes   No
  
• Is Life Guard present? Yes   No
  
• Is Life Saving Equipment present? Yes   No
  

Property Coverage Information

Type of Structure (Select One):
 Frame
 Brick w/wood joists
 Brick & Block w/concrete & Steele Roof and Floors

Year Built

Are Sprinklers Present? Yes   No

Distance to Fire Hydrant

Distance to Fire Department

Amount needed to replace all equipment, furniture
and fixtures, tenants improvements and betterments

If building coverage is desired,
amount needed to replace the building

Maximum amount of cash on hand at any one time

General Liability Coverage Information:

Limit of Coverage Desired:
 $300,000
 $500,000
 $1,000,000

Umbrella Limit Desired:
 None
 $1,000,000
 $2,000,000
 $3,000,000
 $4,000,000
 $5,000,000
 More

Number of Square Feet Occupied

Work Comp Coverage Information:

Federal Employee ID Number

Names of Corporate Officers, and do they
want to be covered (Included/Excluded):

Corporate Officer #1:
Name:   Include   Exclude

Corporate Officer #2:
Name:   Include   Exclude

Corporate Officer #3:
Name:   Include   Exclude

Corporate Officer #4:
Name:   Include   Exclude

Payroll for code 9063 - Health Clubs

Automobile
   Please call for a quote on commercial auto insurance.