DBA Name of Business
*
Name
*
First Name
Last Name
Phone Number
Email
*
Preferred Contact Method
*
Mailing Address (if different)
Facility Type
*
Other:
Year the business started:
*
Do you own or rent the facility?
*
Own
Rent
If renting, please provide Landlord Name and Address:
Do you sublease or rent space to others?
*
Yes
No
If yes, how many square feet?
If yes, to whom and what is the purpose:
Do you engage in any other operations as the Named Insured above?
*
Yes
No
If yes, explain:
Is the applicant of a subsidiary of another entity or does the applicant have any subsidiaries?
*
Yes
No
Desired General Liability Limits or Limits Required in Lease:
*
Do you own any vehicles in your business?
*
Yes
No
If so, do you have a business auto policy in place?
Yes
No
Would you like a quote for Hired and Non-Owned Auto Coverage?
Yes
No
Is your facility part of a franchise group?
Yes
No
If yes, what group:
Is facility currently insured?
*
Yes
No
Current Insurance Carrier:
Price of Current Insurance Policy:
Have you ever been cancelled, non-renewed, or denied insurance on a liability policy?
*
Yes
No
If yes, explain:
If yes, please explain:
Membership Dues:
*
Initiation Fees:
*
Pro Shop:
*
Tanning:
*
Rental from Leased Space:
*
Other:
If other, please describe:
Does your facility derive 80% or more of the revenue from personal training, circuit training, or small group training?
*
Yes
No
Total Number of Full-Time Employees:
*
Total Number of Part-Time Employees:
*
Total Number of Contractors:
*
Do you employ or contract with any of the following at your facility?
*
Other:
Do you require all independent contractors to carry their own insurance?
Yes
No
Average cost of membership/session/class:
*
Number of Active Members/Clients/Students:
*
Does the facility contain any?
*
Please select all that apply
Manufacturer(s) of Equipment
*
Age of Equipment
*
Do you use "home made" or "modified" equipment?
*
Yes
No
Do you keep Equipment logs?
*
Yes
No
Does an outside vendor perform your equipment maintenance?
*
Yes
No
If yes, who?
Is your equipment and building in good repair and maintained?
*
Yes
No
If no, explain:
Do you provide childcare or offer youth activities?
*
Yes
No
If yes, please explain:
If yes, Staff to Child ratio:
What is the maximum hours allowed to stay?
Do you have outdoor playgrounds for children?
Yes
No
Do you have written guidelines in place for preventing minors being left alone with adults?
Yes
No
Do you perform criminal background check on employees and independent contractors?
*
Yes
No
Do any of your employees have known convictions or allegations of sexual offenses?
*
Yes
No
Do you have a licensed daycare facility?
*
Yes
No
Do you offer gymnastics?
*
Yes
No
Do you offer summer camps, day camps or parties?
*
Yes
No
Do you offer after school programs for children?
*
Yes
No
Do you host special events?
*
Yes
No
If yes, please describe:
Do you have separate coverage in place for your Special Event?
Yes
No
If yes, please describe:
Do you have any lock-ins or other special events that have over-night exposure?
*
Yes
No
If yes, please describe:
Do you host any events outside of the US?
Yes
No
Do you require signed waivers from all clients?
*
Yes
No
Is safety signage used throughout the facility?
*
Yes
No
Do you have non-slip surfaces in ALL wet areas?
*
Yes
No
Do you have showers in your facility?
*
Yes
No
Do you have a daily cleaning schedule?
*
Yes
No
Do you operate an unstaffed club, key club or 24/7 access club?
*
Yes
No
Is the owner on site during all hours of operation?
*
Yes
No
Do you conduct orientation for all new members?
*
Yes
No
Do you have a restaurant or snack bar?
*
Yes
No
If yes, is there cooking?
Yes
No
Do you own your own parking lot?
*
Yes
No
Do you produce videos?
*
Yes
No
Construction Type of the Building:
*
What percentage or square footage of the building do you occupy?
*
What other occupancies are in the building?
*
If none, please type none
Do you have a fence?
*
Yes
No
If yes, is the fence wooden or metal?
Value of the Fence:
Do you have a sign?
*
Yes
No
If yes, value of the sign:
Year the Roof was last updated:
*
Year the Electrical/Wiring was last updated:
*
Year the Plumbing was last updated:
*
Year the Heating/HVAC was last updated:
*
Do you have a Burglar Alarm?
*
If yes, who services the Burglar Alarm?
Is there a safe on premises?
*
Yes
No
Do you have Fire Protection?
*
Is the building sprinklered?
*
Yes
No
If yes, what percentage of the building is sprinklered?
Do you have a Fire Alarm?
*
Does the Facility currently carry Property Insurance?
*
Yes
No
Current Property Insurance Carrier:
Current Price of Property Insurance Policy:
If yes, Value of Building:
Value of Tenant Betterments/Improvements:
Do you offer any of the following Spa Services?
Please select all that apply
Other:
Do you offer any additional procedures or processes designed to remove layers of skin (other than enzyme exfoliation)?
Yes
No
If yes, please explain:
Do you manufacture or custom mix any of your own products?
Yes
No
If yes, please explain:
Name the style you teach:
Federation or Association:
Level of contact:
Belt Rank of Owner/Primary Instructor:
Number of years teaching experience:
Number of active students:
Ratio of instructors to students:
Age range of students:
Do you participate in tournament(s)?
Yes
No
Do you practice Sparring?
Yes
No
Do you do off-premise demonstration?
Yes
No
Do you offer kick-boxing?
Yes
No
Do you have weapons training?
Yes
No
If yes, explain:
What other type of equipment is used on premise?
Do you perform criminal background check on employees and independent contractors?
Yes
No
Do any of your employees have known convictions or allegations of sexual offenses?
Yes
No
Do you offer after school or summer camps?
Yes
No
Do you have written guidelines in place for preventing minors being left alone with adults?
Yes
No
Number of Students:
Style(s) that you teach:
Number of Recitals:
Are Recitals:
Do you teach private lessons?
Yes
No
Do you teach adults?
Yes
No
Do you teach children?
Yes
No
Age(s) of children:
Do you perform criminal background check on employees and independent contractors?
Yes
No
Do any of your employees have known convictions or allegations of sexual offenses?
Yes
No
Do you have a performing company?
Yes
No
Do you operate a dance club?
Yes
No
Do you have written guidelines in place for preventing minors being left alone with adults?
Yes
No
Total Number of Students:
Number of workshops or retreats:
Are they:
Do you teach children?
Yes
No
Age(s) of children:
Do you perform criminal background check on employees and independent contractors?
Yes
No
Do any of your employees have known convictions or allegations of sexual offenses?
Yes
No
Do you offer over-night retreats?
Yes
No
Additional Notes:
