Fitness Center Insurance Questionnaire

Mailing Address - continued

GENERAL LIABILITY (Attach a copy of the club’s sales brochure.)

	Yes	No
Boxing activities (aerobic only, no sparring) - If yes, describe below
Kickboxing activities (aerobic only, no sparring) - If yes, describe below
Cheerleading activities- If yes, describe below
Gymnastic activities - If yes, please describe what is included besides tumbling and floor exercises

LicensedCertifiedRegistered (Iowa)None

Note: Center MUST be licensed or certified to be considered for coverage (or "Registered" for Iowa only. (Attach copy of state license)

	Location 1	Location 2	Location 3
Number of Children

	Full-Time	Part-Time
Number of Employees
Number of Volunteers

Private VehicleHired VehiclesPublic TransportationOther

	Number of Trainers	Number of Students	Sales ($)
Personal Trainers
Fitness Instructors
Yoga Instructors
Dance Instructors

	Yes	No	If yes, number
Showers?
Jacuzzis / Whirlpools?
Sauna?
Steam Rooms?

	Yes	No
12i. All pools used are approved by the National Swimming Pool Institute and/or the American Public Health Association
12j. Pools are equipped with proper depth and lane markings
12k. Pools have applicable rules visibly posted for all participants
12l. Have all drains been updated to meet Safety Vacuum Release System standards?

	Height	Water Depth
Board 1
Board 2
Board 3

	Yes	No	N/A
12r. Is training provided for racing dives?
12s. Are racing dives or dives from starting blocks performed in water with a minimum depth of five (5) ft. or more?
12t. Are all dives from one meter or higher performed with a minimum of 10 feet of water in the well?
12u. Are all dives from 3 meters or higher performed with a minimum of 11 feet of water in the well?

	Yes	No	Number of Indoor	Number of Outdoor	Describe Type	Describe Condition
Tennis Courts
Racquetball, Handball, Squash Courts
Sports Courts - Volleyball, Basketball
Tracks

ABUSE & MOLESTATION (If located in Illinois, this section MUST be completed.)

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2

Replacement CostActual CostTotal Value ($)

	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

COMMERCIAL AUTOMOBILE INSURANCE

	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

DIRECTORS AND OFFICERS INSURANCE

WORKERS' COMPENSATION INSURANCE

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://insurancefitnesscenter.com/

	Yes	No
Boxing? (Aerobic only, no sparring.)
Kickboxing? (Aerobic only, no sparring.)
MMA? (Aerobic only, no sparring.)

	Yes	No
4a. Child/Sexual Abuse and Molestation
4b. How to recognize the signs of abuse
4c. What to do if a client/child reports someone molested him/her