CAPP0050815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – CLUBS - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
Types of Clubs requiring a different supplemental application:
Country, Golf, Tennis, Home-owner associations, Racquet ball, Hunting, Exercise & health or Swim clubs
PROHIBITED (check all that apply to your operations)
Bicycles, Cars, Motorcycles
Counseling
Dating
Fraternities or sororities
Horse riding
Sailing, Scuba, Yachting, Water Skiing
Sky Diving
Snowmobile, Skiing
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
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CLUBS - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES
Describe type of club, or purpose of club:
Beach(es) Total length: __________ feet
Lake(s) Total acres: __________ Lakes must be posted to prohibit swimming
Land – total number of acres owned by the club: __________ acres
Off Premises Activities (describe):
OPERATIONS / EXPOSURES
Swimming Pool(s) Number of swimming pools: __________
Meets Federal swimming pool/spa drain cover standards found in the Virginia Graeme Baker Pool
and Spa Safety Act
Depths marked, Life safety equipment placed in pool area, Rules posted
Competitions Diving Teams Swimming Instruction
Fenced completely with self-latching gate(s), , if pool is outdoors
Life guards CPR trained Subcontracted out
Slides or diving boards Maximum height: __________ feet
SUBCONTRACTORS / INDEPENDENT CONTRACTORS
Uninsured subcontractors are not acceptable.
Risk Transfer – Subcontractors:
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of insurance - Always obtained from a subcontractor prior to any work being done for you.
Limits of Liability - Subcontractors are required to carry limits equal or above your own
CLUB MEMBERS
Number of annual memberships: ____________
RECEIPTS
All Operations including liquor receipts
$
Liquor Receipts Only
$
PLANNED EXPANSION OR NEW ACTIVITIES IN COMING POLICY TERM
New activities or expansion is anticipated (describe):
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CLUBS - SUPPLEMENTAL APPLICATION
COVERAGE OPTIONS - LIABILITY (check if you would like an optional quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Liquor Liability (requires separate liquor liability supplemental application)
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like an optional quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement: Bronze – U777C Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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