Skating Rink Insurance Questionnaire

Skating Rink 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: ($)
Ice Skating Rinks | Roller Skating Rinks | Pro Shops | Concessions
GENERAL INFORMATION
1. Liability Coverage (check coverage desired):

General Liability
GL Occurrence Limits desired:
GL Aggregate Limits desired:
2. Do you want Abuse & Molestation coverage (available for youth leagues)?

YesNo
3. 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. How many years have you been in business?
2. What is your annual payroll (excluding owners, officers, and support staff)?
2a. Please indicate the number of employees:

Part-Time Full-Time

Number of Employees
2b. What pre-employment screening is used? Please explain:
3. Do you ever hire sub-contractors/independent contractors that carry their own insurance?

YesNo
3a. If yes, please provide details:
3b. If yes, are certificates of insurance provided?

YesNo
3c. Do you require contractors to name you as additional insured on their policy?

YesNo
3d. Total Cost ($):
4. Do you require participants/members (or parents of minors) to sign an injury waiver? (Please provide a copy.)

YesNo

	Part-Time	Full-Time
Number of Employees

5. Please enter receipts for each category:

	Receipts ($)
Open Skating (including skate rentals)
Contract Skating - Hockey/Figure
Children's Parties
Roller Derby
Other (Describe below)

5a. Describe "Other "
6. Is rink open year round?

YesNo
6a. If no, please list months in operation:
7. Is there a barrier that separates all skating areas from spectators and other activities?

YesNo
7a. If yes, what is barrier height
8. Do you have any sponsoring or sanctioning organizational affiliations or associations?

YesNo
8a. If yes, please check names:

USAC/RDUSA Roller HockeyISIAHIHAUSFSANRHARSARHIAOther
9. What is the pro-shop exposure?

Your operationLessor's risk
9a. Pro Shop Sales & Repairs Receipts (Rental income if leased out)
10. Do you operate a roller rink?

YesNo
10a. Surface Composition:

Please enter info below:

	Enter number below
10b. Number of Skating Surfaces
10c. Number of Rink Guards
10d. Maximum rink capacity at any one time
10e. Maximum number of skaters per floor per floor guard?

11. Do you operate an ice rink?

YesNo
11a. Surface Composition:

Please enter info below:

	Enter number below
11b. Number of Skating Surfaces
11c. Number of Rink Guards
11d. Maximum rink capacity at any one time
11e. Maximum number of skaters per floor per floor guard?

11f. Is there regular maintenance of ice surfacing equipment?

YesNo
11fi. If yes, by whom (include experience):
11g. Fuel source of ice resurfacing equipment:

GasElectricPropane
11h. Is there proper draining in ice resurfacing room?

YesNo
12. Do you offer any competitive sports, such as hockey, broomball, soccer, etc.

YesNo
12a. Are barriers installed behind goals?

YesNo
12b. Are barriers installed around perimeter and surface?

YesNo
12c. What are the heights of the barriers behind the goals and sides?
12d. Are barriers plexiglass?

YesNo
12di. If yes, is it?

StruttedSeamed
12e. Wire mesh or Chain link?

YesNo
12f. Do you have dasher boards?

YesNo
12fi. Netting on dasher boards?

YesNo
12g. Do you have hockey nets?

YesNo
12gi. If yes, are they?

Breakaway / Rest on surfaceAnchored / Bolted to surface
13. Do you occupy 100% of the entire building?

YesNo
13a. If no, please list other occupants:
14. Do you have cooking facilities?

YesNo

14a. If yes, indicate which of the following apply and the number of each:

	Enter number below
Ranges
Ovens
Deep Fryers
Grills
Broilers
Griddles

14b. If yes, are all cooking surfaces covered by an UL300 Extinguishing system?

YesNo
14bi. Hoods/ducts cleaned by contractor?

YesNo
14bii. How often?

MonthlyQuarterlySemi-AnnuallyAnnually
14c. If yes, is there a 40 BC fire extinguisher in the kitchen?

YesNo
14ci. If yes, last date serviced?
14d. Are food operations handled by?

InsuredSubcontractor
14di. If subcontracted, do you require a Certificate of Insurance?

YesNo

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. Who is responsible for maintaining and doing safety inspections of the facility?
3. Who has the authority to cancel the activity if there is a safety concern?
4. Are there bleachers or a grandstand?

YesNo

4a. If yes to bleachers or grandstand:

	Number of Rows	Construction Type	Condition
Enter info

4b. If yes, are there railings on the back and sides?

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

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

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

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

YesNo
8a. 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:

	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:

	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:

	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:

	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:

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

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

	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:

Youngest Oldest

Age
11. Is the camp co-ed?

YesNo
11a. Percentage of:

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?

Instructors Participants

Ratio

	Youngest	Oldest
Age

	Male (%)	Female (%)
Age

	Instructors	Participants
Ratio

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

	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:

	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:

	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.)

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

2b. If yes, limits desired:

	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? ($)
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

Clear
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/
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