• Fitness Center Insurance Questionnaire

  • Applicant is:
  • How did you hear about us?

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

  • 4b. Are independent contractors required to provide certification of insurance? (Copy please.)
  • 4c. Do you require contractors to name you as additional insured on their policy?
  • 6. Is the facility open 24 hours?
  • 8. Do you only have equipment authorized by the franchisee?

  • SERVICES PROVIDED

  • 1. Does the facility conduct...
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  • 2. Does the facility conduct licensed childcare services?
  • 2a. Is the center:
  • Note: Center MUST be licensed or certified to be considered for coverage (or "Registered" for Iowa only. (Attach copy of state license)
  • 2c. In the past 12 months, have any complaints been filed with the Licensing Board against applicant’s facility?
  • 2d. In the past 3 years has any of the applicant’s licenses been revoked, suspended or placed under probation?
  • 2e. How many children is the application licensed to care for?
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  • 2f. Is applicant licensed/certified for: (Grades 1–12 & home schools are not eligible)
  • 2h. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective employees? (If no, Abuse and Molestation coverage is not available.)
  • 2i. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective volunteers? (If no, Abuse and Molestation coverage is not available.)
  • 2j. Does applicant have a Student Accident Insurance Policy in effect?
  • 2k. If the applicant has any employees or volunteers, please complete all of the following questions:
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  • 2ki. Has there ever been an allegation of sexual abuse made against the employee or volunteer?
  • 2l. If located in a commercial building, are there any other occupants in this building?
  • 2m. Does the applicant own the building?
  • 2mi. Does the insured lease any space to other tenants?
  • 2miii. Are any residential apartments located within this building? (Attach copy of tenant's HO4 & Lease Agreement.)
  • 2n. Does the applicant provide any transportation of children?
  • 2ni. Do you transport children in:
  • 2nii. Do you have a Commercial Auto policy?
  • 3. Does the facility provide:
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  • 3c. Do the trainers/instructors provide training services off premises?
  • 4. Does the facility conduct martial arts activities?
  • 4d. Light contact?
  • 4d. Full contact?
  • 4e. Does the school engage in sparring?
  • 4f. Is there any sparring with weapons? (Contact with weapons unacceptable)
  • 4h. Any protective gear used?
  • 4k. Do students participate in tournaments?
  • 4l. Do you require a signed Hold Harmless agreement from students? (or from parents, if a minor?) If yes, please provide a copy.
  • 4m. Does school engage in:
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  • 5. Does the facility conduct massage therapy?
  • 6. Does the facility conduct nutritional counseling?
  • 8. Does the facility provide physical therapy?
  • 8b. Is any Medical Professional Liability Coverage in place?
  • 9. Does the facility contain a restaurant or snack bar?
  • 9b. If yes, is there an Automatic Fire Extinguishing System over all cooking surfaces?
  • 10. Does the facility sell sporting goods or clothing?
  • 11. Does the facility contain...
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  • 12. Does the facility contain swimming pools?
  • 12b. Are the pools
  • 12c. Are the facilities inspected before every session?
  • 12h. During swim meets and practices, is there a lifeguard, coach, or some other qualified official acting as a lifeguard?
  • Safety checklist: the following guidelines must be met in order to be eligible for coverage:
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  • 12m. Is diving permitted? If yes, answer questions below.
  • 12n. List height & water depth for each diving board
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  • 12p. Is there platform diving?
  • Dives
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  • 12v. Are there any slides or anchored floating devices?
  • 13. Does the facility contain tanning beds/booths?
  • 13c. Do customers sign a waiver of liability before using the beds?
  • 14. Other activities:
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  • 15. Do you have climbing walls?
  • 15e. Are belayers certified?
  • 16. Any other recreational services, children’s activities, field trips off-premises, etc.

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

  • 1. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective employees and volunteers?
  • 2. Does the applicant verify employment-related references?
  • 3. Does the applicant conduct personal interviews?
  • 4. Does the applicant discuss the following items at staff orientation?
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  • 5. Does the applicant have knowledge of any incident which could give rise to, or result in, an allegation of sexual abuse?
  • 5. Has there ever been an allegation of sexual abuse made against the insured?

  • PROPERTY INSURANCE

  • 1. Do you need Building and/or Content Coverage?
  • 1a. If yes, please complete chart below or provide a separate property schedule with the following information:
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  • 2. Do you need Equipment Coverage?
  • 2a. If yes, total value to insure for?
  • 2b. If yes, please complete equipment schedule below or provide a separate equipment schedule with the following information:
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  • 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?
  • 2a. (If yes, complete chart below or provide a separate vehicle/fleet schedule with following info.)
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  • 2b. If yes, limits desired:
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  • 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 INSURANCE

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

  • WORKERS' COMPENSATION INSURANCE

  • 1. Is there a written return to work program in place, to encourage/assist employee in rejoining the work force? If yes, please attach a copy.
  • 2. Does the insured provide a major medical health insurance for their employees?
  • 3. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)
  • Privacy Policy and Terms & Conditions*

  • 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
    kmorency@morencyinsurance.com 

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

    https://insurancefitnesscenter.com/

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