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

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  • 59 check-boxes
  • 21 other fields

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File type: PDF

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C‐APP013‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – EXERCISE AND HEALTH 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:
PROHIBITED
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
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
Weight loss centers, diet centers or diet-related spas
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‐APP013‐0815 Page2of3
EXERCISE AND HEALTH CLUBS - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES
Babysitting / Childcare Services – Age groups:
Birth to 6 months
16 months to 2 years
2 years to 4 years
4 years to school age
School Age
Ratio of staff to children: 1 to _____
Play area(s) if outdoors are fully fenced with self-locking gates
State required certifications in place
Waiver and release of liability specific to babysitting is in contract
Off Premises Activities (describe)
Snack bar
Restaurant (Requires Restaurant Supplemental Application)
Sauna(s) / Steam Room(s)
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
Tanning Beds (if exposure present submit separate tanning bed 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: (check if applicable)
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 annual memberships: __________
Club member contracts include a ‘Release of Liability’ and ‘Waiver’
RECEIPTS
All Operations
$
C‐APP013‐0815 Page3of3
EXERCISE AND HEALTH CLUBS - SUPPLEMENTAL APPLICATION
PLANNED EXPANSION OR NEW ACTIVITIES IN COMING POLICY TERM
New activities or expansion is anticipated (describe):
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
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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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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