• Club Insurance Questionnaire

  • Applicant is:

  • GENERAL INFORMATION

  • 5. Is the club restricted to club members and their guests?
  • 7. Is indoor smoking allowed?
  • 8. Check all that apply to your operation:
  • 10. Any international operations? (If yes, describe by attachment.)
  • 11. Do you engage in fundraising? (If yes, describe below in section for events.)
  • 12. Any medical services or medical advice of any kind provided to members or to the public?
  • 13. Are any kinds of personal care or medical care services provided in any capacity?

  • FACILITY RENTAL

    (Complete this section if your organization rents your premises to others (receptions, parties, etc.))

  • 3. Are employees always on-site during facility rental?
  • 4. Is alcohol served or allowed on the premises during facility rental?
  • 5. Are renters required to sign a written rental contract? (If yes, please provide a copy of the rental contract).

  • CLUBHOUSE

  • 1. Tavern or restaurant occupancy?
  • Rows
  • 3. Is alcohol served or allowed on the premises?
  • Note: If Liquor Liability coverage is desired, please contact Kevin Morency for a quote. (Liquor Liability will only be available if we provide the General Liability for your club operation.)

  • EVENT INFORMATION

  • Rows

  • Note: Events which are not restricted to club members and their guests, attracting more than 200 attendees, require the completion of a West Bend Special Events Questionnaire.

  • 2. Do you rent out the premises to non-members?
  • 2a. If yes, do you require proof of insurance and are you named as additional insured on their policy?
  • 3. Are you a professional or trade association?
  • 4. Are you a Neighborhood Association?

  • PROPERTY INSURANCE

  • 1. Do you need Building and/or Content Coverage?
  • Rows
  • 2. Do you need Equipment Coverage?
  • 2a. If yes, total value to insure for?
  • Rows

  • COMMERCIAL AUTOMOBILE INSURANCE

  • 1. Does the business title any automobiles or other operating vehicles in the business name?
  • 2. Is insurance coverage needed for owned automobiles?
  • Rows
  • Rows
  • 3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?
  • 3b. Do you verify they have liability coverage?

  • COMMERCIAL CRIME

  • 1. Do you desire coverage for Crime (Employee Dishonesty, Money, Forgery)?

  • COMMERCIAL UMBRELLA

  • 1. Do you need a Commercial Umbrella?

  • DIRECTORS AND OFFICERS & WORKERS' COMPENSATION INSURANCE

  • 1. Do you need Directors and Officers Liability Coverage? (If yes, please contact Kevin Morency.)
  • 2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

  • SIGNATURE

  • The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.

  • Questions? 877-244-9090
    Kevin Morency |  kmorency@morencyinsurance.com 

    Morency & Associates Inc.
    141 New Shackle Island Rd, Hendersonville, TN 37075
    Fax: 615-452-6580

    https://clubassociationinsurance.com/

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