Health Club Insurance Application Form

Please enable JavaScript in your browser to complete this form.

- Step 1 of 13

CAUTION: You will not be able to save this application. It must be filled out in its entirety. Do not click the back button in your browser or you risk losing information already completed. If you need to review previous pages before submitting, please click the “Previous” button at the bottom of the page.

Are you a broker? *

Business Name

Brokerage Name

Broker Address

Layout

Broker City

Broker Province

Layout

Broker Country

Broker Postal Code

Layout

Broker Telephone

Broker Email

Layout

Location Address

Layout (copy) (copy)

Location City

Location Province

Layout (copy)

Location Country

Location Postal Code

Mailing Address

Layout (copy)

Mailing City

Mailing Province

Layout

Mailing Country

Mailing Postal Code

Owner/Operator

Layout

Bus #

Fax

Layout

Cell #

Res #

Alternative Contact

Alternative Phone

Alternative Email

Website / URL

Layout

Current Insurance Company

Expiry Date of Current Policy

Layout

Retroactive Date of Current Policy

Target Premium

Layout

Number of years in business?

Have you ever been cancelled for nonpayment?

PROPERTY INFORMATION

Describe your location (strip plaza, shopping mall, etc.)

Layout

Building Age (year built)

Do you own the building?

Layout

Total Area of Building (sq. ft.)

Total Area of your Facility (sq. ft.)

Layout

Sprinkler System

Monitored Alarm

Fire Hydrants within 500 feet

Layout

Is there Any Bar/Restaurant Adjacent to your operation?

Does your location include a basement?

Describe precautions taken to avoid slips and falls at entrances

Do you have any equipment stored offsite? (i.e. home office)

Please describe

CONSTRUCTION OF BUILDING

Constr 1

Fire-Resistant:

Structures/buildings must be made of reinforced concrete or protected steel

Non-Combustible:

Building has exterior walls made of masonry materials, such as brick, concrete, hollow concrete block, stone, or other similar materials, with floors and roof constructed of metal

Constru 2

Masonry:

Brick veneer & combination of steel, concrete and wood

Frame:

Wood, tar and brick or similar materials

Layout

LATEST UPDATES

Roof

If the building 20+ yrs old, this line is required

UPDATE TYPE

Roofing Update Type

FULL
PARTIAL

COMPLETED

Roofing Year Update

TO CODE

Roofing To Code

Layout

Heat

If the building is 35+ yrs old, this line is required

Heating Update Type

FULL
PARTIAL

Heating Year Update

Heating To Code

Layout

Plumbing

If the building is 35+ yrs old, this line is required

Plumbing Update Type

FULL
PARTIAL

Plumbing Year Update

Plumbing To Code

Layout

Electrical

If the building is 35+ yrs old, this line is required

Electrical Update Type

FULL
PARTIAL

Electrical Year Update

Electrical To Code

Use the following form to help breakdown and calculate accurate replacement cost:

Stock 1

STOCK:

Water/Pre-packaged Snacks $

Clothing/Shoes/Hats $

Other $

Layout 1

EQUIPMENT:

Computers/Laptops $

Stereo/Video Equipment $

Signs $

Layout 2

Furniture $

Machines $

Other $

Lease 1

LEASEHOLDS:

Existing Tenants Improv. $

Washrooms/Showers $

Change Rooms $

Layout 2

Flooring $

Steamrooms/Built in Sauna $

Construction $

Layout 3

Mirrors/ Wall Coverings $

Alarm/Phone Systems $

Other $

Layout

TOTAL CONTENTS (including all stock, equipment & leaseholds above) =$

TOTAL CONTENTS (including all stock, equipment & leaseholds above) $

BUILDING REPLACEMENT VALUE (if required)

Layout

sq.ft Building x

cost/sq.ft

Total = $

DID YOU KNOW:

Many people underestimate and therefore underinsure their property limits. Make sure you list how much it would cost to replace all of the above items today. To help estimate your Leasehold Improvements, you can multiply your square footage by $20 (minimum $/sq. ft. used for this industry).

OTHER BUSINESS(ES)

Other 1

Do you own/operate or rent space to other businesses? $

Total annual rental income $

Other 2

Describe type(s) of business:

EQUIPMENT

Do You Have Modified/Rebuilt/Used Equipment?

If Yes, % used:

Age:

Is Equipment Inspected Daily?

Who Does Maintenance?

LIABILITY INFORMATION

Liability Limit Requested:

$2,000,000
$3,000,000
$4,000,000
$5,000,000

Layout

No. of Members:

# of Employees/Sub-Contractors (incl. Trainers):

ANNUAL RECEIPTS

Receipts 1

Membership $

Training $

Supplements $

Receipts 2

Food $

Alcohol $

Court Fees/Walk-ins $

Receipts 3

Tanning $

Merchandise/Clothing $

Other $

Receipts 4

TOTAL GROSS ANNUAL RECEIPTS $:

DESCRIPTION OF HEALTH CLUB OPERATIONS

Facility Hours:

Layout

Are members able to access the club when no staff is present?

If yes, complete the information below for the hours you are staffed & unstaffed:

Layout

Monday Staffed

Monday Unstaffed

Layout

Tuesday Staffed

Tuesday Unstaffed

Layout

Wednesday Staffed

Wednesday Unstaffed

Layout

Thursday Staffed

Thursday Unstaffed

Layout

Friday Staffed

Friday Unstaffed

Layout

Saturday Staffed

Saturday Unstaffed

Layout

Sunday Staffed

Sunday Unstaffed

Approximate percentage (%) of clients using the facility during unstaffed hours:

Layout

Do the security cameras operate 24 hours?

Layout

If no, do they operate during unstaffed hours?

How do you prevent multiple people entering the facility using the same card?

Can guest passes be used during unsupervised hours?

If clients abuse their privileges, are they prevented from using the facility when unstaffed?

Are participants under the age of 18 able to access the facility during unstaffed hours?

Layout 1

Is there staff present during all operating hours?

Minimum age of Participants/Members:

Layout 2

Do the security cameras operate 24 hours?

Layout

If no, do they operate during unstaffed hours?

Layout

Do members sign waivers?

Layout

Do you ever serve alcohol?

Layout

Do you have a liquor license?

Layout

Do you sell supplements?

Layout

Do any contain ephedra or other metabolic enhancers?

Describe any activities away from the premises:

List all programs offered:

ADDITIONAL OPERATIONS

Layout

List one

Trampoline
Crossfit
Fighting Ring
Snack Bar
Hot Yoga
Tanning Beds **

**The Description of Tanning Operations and Beds/Booths tables must be completed.

List Two

Gymnastics
Boxing/Kickboxing
Kids Programs
Physical Therapy
Golf Simulator

List Three

Rock Climbing Wall
Martial Arts
Massage
Weight Loss Programs

Vibrations Machines #

DESCRIPTION OF TANNING OPERATIONS**

Are you a full member of SmartTan Association (or other tanning association)?

Are all staff trained or certified through SmartTan or equivalent certifying body?

Clients 1

Are clients given tanning instruction?

Clients 2

Minimum age of Tanning Clients:

Are tanning goggles supplied and required to be used?

Do you complete a skin analysis for every client?

Is touching of clients allowed by staff?

Are beds cleaned after every use?

Minimum time allowed between tans per client:

Do all clients sign waivers?

Vibrations Machines

How Many Vibrations Machines?

BEDS/BOOTHS

Layout

Beds #

Booths #

Spray Booths #

Air Brush Units #

Layout

Where are timing controls located?

Who sets timers?

Layout

Do electricians service the equipment?

Are any beds coin operated?

Layout

Average age of beds:

Outside dryer vents cleaned at least every 6 months?

Are beds/Booths protected by ground fault interrupted (GFI) circuits?

COURTS

Courts 1

Squash #

Handball #

Racquetball #

Courts 2

Tennis #

Indoor Courts #

Outdoor Courts #

Courts 3

Basketball #

Tennis/Golf Bubbles #

Describe Bubbles:

CHILD MINDING

Contact our underwriting team to discuss options for coverage if you offer any child minding.

WET AREAS

Wet 1

Showers #

Whirlpools #

Pools #

Clients 3

Wet 2

Infra Red Saunas #

Dry Saunas #

Steam Rooms/Wet Saunas #

Are all steam rooms vents/spouts covered/capped to defuse the steam?

Layout

Non-Slip Flooring?

Layout

Rubber Mats In Halls?

ADDITIONS TO THE POLICY

ADDITIONAL INSURED: (Provide full name, address and interest in the policy * i.e. Landlord, contractor, etc.)

LOSS PAYEE: (Provide full name, address and interest in the policy * i.e. leasing co., mortgagee, etc.)

CLAIMS HISTORY

Has the company &/or staff had claims against them in last 5 years?

Loss 1

Date Of Loss 1

Loss Details 1

Amount Paid/Reserve 1

loss 2

Date Of Loss 2

Loss Details 2

Amount Paid/Reserve 2

loss 3

Date Of Loss 3

Loss Details 3

Amount Paid/Reserve 3

I understand and agree that any policy issued will be based upon the information contained in the application and any related forms and correspondence. I understand that any forms or other material submitted with the application constitute part of my application for insurance. I further understand and agree that any misrepresentation or failure to provide true and accurate information may result in the voiding of and/or denial of claims under any policy issued at the option of the company. By submitting this application and any related forms to Sports & Fitness Insurance Canada, you provide Trothen & McConkey Insurance Broker Ltd. with your consent to the collection, use and disclosure of your personal information, including that previously collected, for the purpose of: communicating with you; assessing your application for insurance and underwriting your policies; evaluating claims; detecting and preventing fraud; analyzing business results; and acting as required or authorized by law.

Applicant:

Layout

Signature

Clear Signature

Applicant Name *

First

Last

Layout

Title

Date

Submitting this form may take a few minutes. Please do not leave this page, close the window or go back as your submission may not be completed.

If you would like to receive a copy of the form please provide your email address here:

Health Club Insurance Application Form

PROPERTY INFORMATION

CONSTRUCTION OF BUILDING

Fire-Resistant:

Non-Combustible:

Masonry:

Frame:

LATEST UPDATES

Roof

UPDATE TYPE

COMPLETED

TO CODE

Heat

Plumbing

Electrical

Use the following form to help breakdown and calculate accurate replacement cost:

TOTAL CONTENTS (including all stock, equipment & leaseholds above) =$

BUILDING REPLACEMENT VALUE (if required)

DID YOU KNOW:

OTHER BUSINESS(ES)

EQUIPMENT

LIABILITY INFORMATION

ANNUAL RECEIPTS

DESCRIPTION OF HEALTH CLUB OPERATIONS

Facility Hours:

ADDITIONAL OPERATIONS

DESCRIPTION OF TANNING OPERATIONS**

BEDS/BOOTHS

COURTS

CHILD MINDING

WET AREAS

ADDITIONS TO THE POLICY

CLAIMS HISTORY

Applicant:

Areas of Expertise

Learn More

How Can We Help