Golf Range Insurance Questionnaire

Golf Range Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
Golf Range | Miniature Golf | Golf Leagues | Golf Clinics | Golf Camps
GENERAL INFORMATION
1. Liability Coverage (check coverage desired):

General Liability – including injuries to participants
GL Occurrence Limits desired:
GL Aggregate Limits desired:
2. Do you want Abuse & Molestation coverage (available for youth leagues)

YesNo
3. Participants' medical payments: (Choose one)

$1,000$2,500
Please list locations and buildings at each location (List additional locations on separate page)
Location 1: Address and number of buildings
Location 2: Address and number of buildings
OPERATIONS
1. Dates of operation:
2. Age of participants/members (check one or both):

Under 1919 or older
3. Please indicate membership or affiliation with any state, national and/or international association/organization:
4. Do you require participants/members (or parents of minors) to sign an injury waiver? (Please provide a copy.)

YesNo

5. What methods of instruction do you use?

GamesDrillsLecturesOther
5a. Describe "Other "
6. What equipment do you provide?
7. Is play/instruction?

OutsideInsideBoth
8. Number of Stalls/Tee Boxes:
9. Are there partitions between stalls/tee boxes?

YesNo
9a. If yes, how high are the dividers?
9b. If yes, describe partitions between tee boxes.
10. Maximum one (1) person allowed per tee box?

YesNo
11. Are there any two-tier driving platforms? (If yes, please provide picture.)

YesNo
11a. If yes, describe barriers
12. Are other attractions exposed to the range?

YesNo
12a. Explain:
13. Do all ranges face away from the public access areas?

YesNo
14. Is the range fenced in?

YesNo
15. Is there a safety zone of at least 30 feet between the range, parking lots, roads, etc.?

YesNo
16. Do you rent your location for indoor or outdoor special events?

YesNo
17. Do you offer any under-21 Golf Camps?

YesNo
18. Do you occupy 100% of the entire building?

YesNo
18a. If no, please list other occupants:
19. Is any of the property to be insured seasonally occupied?

YesNo
19a. If yes, please specify location and period unoccupied.
20. Is your operation located at a golf course with 9 holes or more?

YesNo
20a. If yes, are you responsible for the maintenance and/or operation of the course?

YesNo
21. Do you ever hire sub-contractors/independent contractors that carry their own insurance?

YesNo
21a. If yes, please provide details:
21b. If yes, are certificates of insurance provided?

YesNo
21c. Do you require contractors to name you as additional insured on their policy?

YesNo
21d. Total Cost ($):
22. Do you have cooking facilities?

YesNo

22a. If yes, indicate which of the following apply and the number of each:

Rows	Enter number below
Ranges
Ovens
Deep Fryers
Grills
Broilers
Griddles

22b. If yes, are all cooking surfaces covered by an UL300 Extinguishing system?

YesNo
22bi. Hoods/ducts cleaned by contractor?

YesNo
22bii. How often?

MonthlyQuarterlySemi-AnnuallyAnnually
22c. If yes, is there a 40 BC fire extinguisher in the kitchen?

YesNo
22ci. If yes, last date serviced?
22d. Are food operations handled by?

InsuredSubcontractor
22di. If subcontracted, do you require a Certificate of Insurance?

YesNo

23. Annual Receipts of Operations:

Rows	Amount ($)
Golf Range, including lessons:
Golf Shop, including golf club repairs:
Miniature Golf:
Video/Arcade Games:
Snack Bar/Ice Cream:
Restaurant:
Liquor/Beer/Wine:
Par 3:
Golf Camps/Clinics:
Other: (Describe below)
TOTAL RECEIPTS

23a. If sit-down restaurant, number of tables:
23b. If Par 3 course, number of holes:
23c. Describe "Other"
24. In the event of unsafe facility conditions, who has the authority to cancel the event?

MINIATURE GOLF OPERATIONS
1. Describe your operations including a complete list of activities. Please attach a flier if available.

2. Please complete table:

Rows	Enter Number Below
Receipts
Number of Attendants
Total Number of Holes
Number of Courses

3. Do fountains and waterfalls have ground fault interrupters in place?

YesNo
4. Is appropriate safety warning and rule/regulation signs posted at club rental counter and/or hole #1?

YesNo
5. Do you sell or rent any equipment?

YesNo
5a. If yes, what are annual sales?
5b. If yes, please describe:
SPORT FACILITIES
1. Do you own the field/facility?

YesNo
1a. If no, who is the owner?
1b. Is location listed under "General Information"? If not, please list here.
2. Are there bleachers or a grandstand?

YesNo

2a. If yes to bleachers or grandstand:

Rows	Number of Rows	Construction Type	Condition
Enter info

2b. If yes, are there railings on the back and sides?

YesNo
3. Do you sell or rent any equipment to the camp participants?

YesNo
4a. If yes, please describe:
4b. If yes, annual sales amount:
5. Do you sell any food or beverages?

YesNo
5a. If yes, please describe:
5b. If yes, annual sales amount:
6. Are there any non-sport activities?

YesNo
6a. If yes, please describe:
7. Do you host any banquets?

YesNo
7a. If yes, please explain:

MEDICAL ASSISTANCE
1. Is there an accident/medical policy for participants/members?

YesNo
1a. If yes, with what company?
2. Are first aid kits available?

YesNo
3. Is any of your staff certified in:

CPRFirst Aid
3a. If yes, please describe:
4. Other medical help:
4a. Location
4b. Distance
5. Do you have a written crisis/disaster management plan? (If yes, please provide.)

YesNo
6. Do you have a written medical emergency plan? (If yes, please provide.)

YesNo
7. Are annual background checks done on all staff?

YesNo
SEXUAL ABUSE - (If located in Illinois, this section MUST be completed. If located in other states, complete only if you desire coverage.)

1. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse-related offenses:

Rows	Yes	No
1a. On prospective employees and volunteers?
1b. On existing employees and volunteers?

1c. How often?
2. Does the applicant verify employment/volunteer-related references?

YesNo
2a. If yes, how?
2b. If yes, how often?
3. Does the applicant conduct personal interviews?

YesNo

4. Does the applicant discuss the following items at staff orientation:

Rows	Yes	No
4a. Abuse and Molestation?
4b. How to recognize the signs of abuse?
4c. What to do if an individual reports someone molested him/her?

5. Does applicant have supervision plan to monitor staff in day-to-day relationships with clients/children?

YesNo
6. Does the applicant have knowledge of any incident which could give rise to, or result in, an allegation of sexual abuse?

YesNo
6a. If yes, please explain:
7. Has there ever been an allegation of sexual abuse made against the insured?

YesNo
7a. If yes, please explain:

LEAGUES
1. Do you offer leagues?

YesNo
1a. Number of teams:
1b. Total number of games played per season (include playoffs, championships, and tournaments)
1c. Does the league provide umpires, referees, or other officials?

YesNo
1ci. If yes, please explain:
1d. Does the league provide training for officials, team managers, or coaches?

YesNo
1di. If yes, please explain:
1e. Youth Leagues: Are written procedures in place for the prevention of abuse and molestation?

YesNo
1f. Has there ever been any allegation of sexual abuse, misconduct or molestation?

YesNo
1fi. If yes, please explain:
CLUBS
1. Do you offer clubs?

YesNo
1a. Number of members:
1b. Are non-members allowed to participate?

YesNo
1c. Number of events/games/races per year?
1d. Does the club provide any officials?

YesNo
1di. If yes, please explain:
1e. Are there any other activities the club hosts or promotes other than the primary sport?

YesNo
1ei. If yes, please explain:
1f. Do members volunteer time to work for the club?

YesNo
1fi. If yes, please explain:
TOURNAMENTS
1. Do you offer tournaments?

YesNo

Please complete table:

Rows	Number
1a. Number of teams participating:
1b. Total number of games:
1c. Approximate number of participants:
1d. Approximate number of spectators:

RACES
1. Do you offer races?

YesNo

Please complete table:

Rows	Number
1a. Approximate number of participants:
1b. Approximate number of spectators:

1c. Who will control road traffic to keep racers safe?

CAMPS
1. Do you offer camps?

YesNo
CAMP OPERATIONS

1. Dates of operation:

Rows	Start Date	End Date
Camp 1
Camp 2
Camp 3
Camp 4

2. Select the sport(s) and camp type:

Rows	Day Only	Day & Overnight
Baseball/Softball
Basketball
Bowling
Football (no tackle)
Soccer
Swimming
Tennis
Volleyball
Wrestling
Other (Describe below)

2a. Describe "Other":
Start Date to End Date
3. Total number of “day only” participants for all day. Example: 16 day only participants for 3 days and 10 day only for 1 day = 58)
4. Total number of “day & overnight” participants for all days. Example: 10 overnight for 20 nights and 12 overnight for 6 nights = 272)
5. Please describe camp (provide copy of any publicity):
6. Is the camp:

Not-for-profitIncorporated
7. Please indicate membership or affiliation with any state and/or national sports organization(s)
8. Are any meals or food provided or sold to participants?

YesNo
8a. a. If yes, who is the provider?
9. Please check any other sports or activities at the camp:

Batting CagesBoatingDiving BoardsHandball or Racquetball CourtsSaddle AnimalsSkiing (Water and Snow)Swimming FacilitiesTrampolinesWeight Training EquipmentOther (Describe below)
9a. If yes to handball or racquetball, number of courts:
9b. Describe "Other"
10. Age range of participants:

Rows Youngest Oldest

Age
11. Is the camp co-ed?

YesNo
11a. Percentage of:

Rows Male (%) Female (%)

Age
12. Are participants (or parents) required to sign waivers? (Please attach a copy.)

YesNo
STAFFING
1. What is the usual ratio of instructors to participants?

Rows Instructors Participants

Ratio

Rows	Youngest	Oldest
Age

Rows	Male (%)	Female (%)
Age

Rows	Instructors	Participants
Ratio

2. Qualification and experience of instructors/volunteers: (use additional page if necessary)

Rows	Name	Position	Qualifications/Experience/Certification
1
2
3

3. Do you employ any medical professionals? (EMT, paramedics, doctors, nurses, therapists)

YesNo
3a. If yes, please describe:
4. Is any of your staff certified in:

YesNo
4a. If yes, please describe:
CAMP TRAVEL
1. Is there any travel away from the camp?

YesNo
1a. If yes, please describe:
2. Describe the mode of transportation:
3. Does the camp own any of the vehicles used?

YesNo
4. Do you verify that all drivers are properly licensed adults with acceptable MVRs?

YesNo
5. Is anyone under age 21 allowed to transport participants?

YesNo
5a. If yes, please describe:
6. Is parent/guardian permission obtained for minors who will be transported?

YesNo
OVERNIGHT CAMPS
1. Do you offer overnight camps?

YesNo
1a. Location of sleeping facilities:
1b. Owner:
1c. Description:
1d. Number of stories:
1e. Do these facilities conform to life safety standards?

YesNo
1f. Are the premises open to the general public?

YesNo
1g. How is security maintained?

PROPERTY INSURANCE
1. Do you need Building and/or Content Coverage?

YesNo

1a. If yes, please complete chart below or provide a separate property schedule with the following information:

Rows	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2
Building 3

2. Do you need Equipment Coverage?

YesNo
2a. If yes, total value to insure for?

Replacement CostActual CostTotal Value ($)

2b. If yes, please complete equipment schedule below or provide a separate equipment schedule with the following information:

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

OPTIONAL PROPERTY COVERAGES
1. Do you need Computer Coverage?

YesNo
1a. If yes, amount needed?
2. Do you need Outdoor Sign Coverage?

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

YesNo
1a. If yes, requested amount?
COMMERCIAL AUTOMOBILE INSURANCE
1. Does the business title any automobiles or other operating vehicles in the business name?

YesNo
2. Is insurance coverage needed for owned automobiles?

YesNo

2a. (If yes, complete chart below or provide a separate vehicle/fleet schedule with following info.)

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

2b. If yes, limits desired:

Rows	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?

YesNo
3a. If yes, how many?
3b. Do you verify they have liability coverage?

YesNo
3c. Limits? ($)
3c. Limits? ($)
COMMERCIAL UMBRELLA
1. Do you need a Commercial Umbrella?

YesNo
1a. If yes, limit of liability needed? ($)
DIRECTORS & OFFICERS LIABILITY AND WORKERS' COMPENSATION INSURANCE
1. Do you need Directors and Officers Liability Coverage? (If yes, please contact Kevin Morency.)

YesNo
2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

YesNo
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.
Signature
Or Enter Your Full Name As Signature:
Date:
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://familyfuninsurance.com/golf-driving-range-insurance/
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