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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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  • 65 check-boxes
  • 24 other fields

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C‐APP028‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - MARTIAL ARTS - 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:
PROHIBITED (check all that apply to your operations)
24 hour facilities, IF not equipped with panic buttons and video surveillance
Boxing, Fighting or Wresting, IF Cage boxing, Professional MMA’s, Ultimate fighting championships
Martial Arts Clubs, Schools or Studios, IF semi-professional or professional (only amateur acceptable)
Medical exposures such as Doctors/Nurses/Physical Therapists on staff, any type of blood analysis, Stress testing
Tanning bed(s), IF attendant does not control timers
Trampolines
Weapons exposures including but not limited to darts, firearms, knives, or swords
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
C‐APP028‐0815 Page2of4
MARTIAL ARTS - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES
Type(s) of martial arts taught (describe):
Boxing ring
Climbing wall
Climbing Wall
Exercise equipment
Exercise room
Heavy bags
Locker room
Showers
Weight room
Off Premises Activities (describe):
Exhibitions sponsored by applicant. If yes, explain:
*Exhibitions are defined as a sponsored event that is open to the public, but participation is limited to the
members of this Martial Arts Club or School
Off-site activities If yes, explain:
Tournament Sponsorship(s) If yes, explain:
*Tournaments are defined as a sponsored event, open to the public, where the members of this Martial Arts Club
Schools are completing with members of another Martial Arts Club or School
Ultimate Fighting Championship participation
Protective equipment includes gloves, headgear
Protective equipment includes mats and/or pads
Sauna(s) / Steam Room(s)
Swimming Pool(s) Number of swimming pools: _______
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
C‐APP028‐0815 Page3of4
MARTIAL ARTS - SUPPLEMENTAL APPLICATION
SUBCONTRACTORS / INDEPENDENT CONTRACTORS
Uninsured subcontractors are not acceptable
Professional Trainers and/or Masseuses who are independent contractors provide certificates of
insurance that confirm liability insurance and professional coverage is in place
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
EMPLOYEES
CPR trained staff member (at least one) is always on duty during hours of operation
Certifications, if required by state law, are verified for all instructors
CLUB MEMBERS
Number of enrollees (annually): __________
Contracts for members include a ‘Release of Liability’ and ‘Waiver’
If member is under the age of 18, parent or legal guardian is required to sing membership contract
Age range 0 -5
Age range 6-12
Age range 13-18
Age range – Over 18
RECEIPTS
All Operations including clothing, equipment, food, tuition fees)
$
PLANNED EXPANSION OR NEW ACTIVITIES IN COMING POLICY TERM
New activities or expansion is anticipated (describe):
COVERAGE OPTIONS - LIABILITY (check if you would like a 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
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like a 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
C‐APP028‐0815 Page4of4
MARTIAL ARTS - SUPPLEMENTAL APPLICATION
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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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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