Health Cluband Sports Facility Questionnaire

HEALTH CLUBAND SPORTS FACILITY QUESTIONNAIRE

• NOTE: This questionnaire is to be submitted along with the following completed forms:
• ACORD Applicant Information Application 125
• ACORD Commercial General Liability Section 126

A.GENERAL INFORMATION
1.Name of Insured (Applicant):
2.Doing business as:
3.Contact person: Phone:
4.Mailing address:
City: State: Zip:
5.What is the insured’s website address? Total Number of Locations:
6.Number of years in business?
Describe management experience:
7,HEALTH CLUBS ANNUAL REVENUE TOTAL:
Membership/Initiation/Enrollment Fees:Child Care:
Personal Training:Retail:
Restaurant/Concessions:Other:
Liquor:
SPORTS FACILITY ANNUAL REVENUE TOTAL:
Facility-organized leagues,
tournaments, lessons, open play, etc.:Child Care:
Third Party Rentals:Retail:
Liquor:Other:
Restaurant / Concessions:
8.Insured is: Corporation Partnership Joint Venture Other: FEIN Number:
9.Does the organization engage in any other business operations under the name of the insured as
it will appear on the policy? Yes No
If yes, explain:
10.Is club a member of IHRSA? Yes No
11.List any Franchise Program where the insured is required to name another entity as an Additional Insured. (i.e. Silver Sneakers, Cross Fit, Parisi Speed School, etc.):
B.UNDERWRITING INFORMATION
1.What is the minimum age requirement to use club facilities?
2.Are minors required to be accompanied by parent or guardian? Yes No
3.Is a Waiver/Hold Harmless signed by member and guest and by the parent or guardian for minor
participants? Yes No
Are waivers signed by all participants? Yes No
4.Is a new waiver signed upon membership renewal? Yes No
5.Please indicate exposures below, and number of each exposure:
Aerobic mini trampoline
Boxing: Contact Non-contact
Camp programs: Day Overnight
Childcare
Circuit training/cardio equip/free weights
Cold plunge
Courts (INDOOR) Description:
Courts (OUTDOOR) Description:
Cryotherapy: Contractor Club operated
Diet center/weight control services: Contractor Club operated
Group classes
Gymnastics
Hot Tubs
Ice/roller skating/blading
Martial Arts (Contact): Contractor Club operated
Martial Arts (No Contact): Contractor Club operated
Massage: Contractor Club operated
Obstacle Course Indoor Outdoor
Personally contracted or manufactured exercise equipment
Physicals/stress testing Contractor Club operated
Pro Shop *
* Describe products sold:
* Are any of the products manufactured under your own label? Yes No
Rock climbing walls (STATIONARY) How many?
Rock climbing walls (PORTABLE) How many?
Running track
Sauna/steam rooms
Snack/juice bar
Spa or salon: Contractor Club operated
Swimming pools (INDOOR) How many?
Swimming pools (OUTDOOR) How many?
Tires
Trampoline
TRX training
Other
6.Any space leased to others? Yes No
If yes, provide the following:
Entity name and description of their operations:
Square footage leased to them:
Lease Revenue:
7.Are Certificates of Insurance naming you as an additional insured obtained? Yes No
8.Is club staffed at all times during open hours? Yes No
9.Total number of full time employees: Part time employees: Volunteers:
10.Number of employees eligible for employee benefits:
11.Does your facility host or sponsor such events as: mud runs, extreme challenge, or anything
similar in exposure? Yes No
12.Does your facility lease out/contract their property for events such as: mud runs, extreme
challenge, or anything similar in exposure? Yes No
If yes, do you require a Certificate of Insurance naming you as an Additional Insured? Yes No
Minimum Liability Limits required with limits of at least $1,000,000? Yes No
Do you require coverage to be shown for both General Liability and for Participant Legal Liability? Yes No
13.Is the facility CrossFit affiliated? Yes No
If yes, provide the annual revenue generated from the CrossFit operations: $
14.Do you participate in CrossFit competition events or activities? Yes No
If yes, explain:
C.FACILITY
1.How often is equipment inspected, maintained?
2.Are maintenance logs maintained? Yes No
3.Who repairs equipment?
4. Does your facility ever use a scissor lift? Yes No
If yes, who operates the scissor lift (i.e. employee, volunteer, independent contractor, etc.)?
Who is responsible for the maintenance of the scissor lift?
If the insured is responsible, describe the maintenance schedule:
Is a maintenance log for the scissor lift maintained? Yes No
5.Is signage used throughout facility to indicate proper use of equipment, club features,
and off-limits areas? Yes No
6.Are there GFI protectors on all outlets in the locker/shower/wet areas? Yes No
7. Are wet areas checked periodically and a log is kept? Yes No
8.Are crews prepared and on duty to clean up spills? Yes No
9.Are restrooms checked/cleaned during operations? Yes No
10.What security features are installed?
Sprinkler system Percent Burglar alarm Fire alarm
Central station alarm Smoke detectors Fire extinguishers
11.Is security lighting provided in your parking lot? Yes No
D.OPERATIONS/PROCEDURES
1.Are the rules posted and enforced at all times? Yes No
2.Are signs clearly posted to identify exits and hazards? Yes No
3.Do you have concussion protocols? Yes No
If yes, what concussion protocol is used and implemented? (i.e. CDC Heads Up, etc.):
4.For in house leagues, do you follow the sanctioning body role? Yes No
5.Is the insured a member of a sanctioning body? Yes No
If yes, provide names:
6.Are instructors employees of the insured? Yes No
If no, are they required to provide certificates of insurance with limits equal to yours and an
additional insured status to you? Yes No
7.Are referees employees of the insured? Yes No
If no, are they required to provide certificates of insurance with limits equal to yours and an
additional insured status to you? Yes No
8.Are there procedures in place to suspend outside play during inclement weather? Yes No
Describe:
9.Are any attending medical professionals available on the premises? Yes No
E.MANAGEMENT/PERSONNEL/SAFETY/SECURITY
1.Are employees certified in CPR or first aid? Yes No
2.What industry recognized certifications do your trainers/instructors have?
3.Does the facility have an Automated External Defibrillator (AED)? Yes No
4.Does your state require you to have available an AED? Yes No
5.Is the AED easily accessible for those who have been trained in the use of the AED? Yes No
6.Do you have AED trained staff on duty during open hours? Yes No
7.Are there written medical emergency and evacuation procedures in place?Provide a copy. Yes No
8.Do any of your employed instructors provide outside services operating on your club’s behalf? Yes No
Please explain:
F.NON-OWNED AND HIRED AUTO (NOHA) (if coverage is desired)
1.Do you have a Business Auto Policy for business-owned autos? Yes No
(If yes, you will need to add hired/non-owned auto to that policy.)
2.Does your operation require employees to drive their personal vehicles for company business
on a regular basis? Yes No
If yes, describe the reasons why they would be using their personal vehicles for company
business:
3.Total # of employees: Total # of volunteers:
4.Do you verify that their personal auto insurance is in place with limits of at least $300,000 before
employees can use their autos for company business? Yes No
5.During the last three years, have you leased, borrowed or hired any vehicles for your business? Yes No
6.If you anticipate some usage this year:
A. What type of vehicle (trucks, cars, buses)?
B. What is the estimated cost to lease or hire the vehicles?
C. Number per month: Number per year:
G.LIQUOR (if coverage is desired)
1. Do you have a bar that is open year round? Yes No
2. Do you stop serving at least one hour prior to closing? Yes No
3. Name on liquor license:
4. Liquor license number: Class of license:
5. Has applicant’s liquor license ever been revoked or suspended? Yes No
If yes, please explain:
6. Has applicant incurred claims for liquor liability during the last 3 years? Yes No
If yes, please explain:
7. Has any insurer cancelled or non-renewed coverage during the last 3 years? Yes No
If yes, please explain:
8. Has applicant ever been fined by alcoholic beverage control or other governmental regulator? Yes No
If yes, please explain:
9. Type of beverages sold:
10.Annual Gross Liquor Sales:$
11.Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If yes, what type?
12.Do you exercise the right of search and seizure of contraband items? Yes No
If yes, how do you notify the public of this?
13. Are the alcohol sales and consumption:
Contained within one fixed site, or are booths/stands located throughout the event site?
14.Do you use Volunteer Servers? Yes No
If yes, please explain supervision:
15.Do all servers receive alcohol awareness training? Yes No
If yes, please explain:
(attach training manuals used)
16.Explain how ID's are checked:
17.Are rules and regulations clearly displayed for patrons viewing? Yes No
Describe:
18.Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No
Explain:
19. Is there entertainment provided? Yes No
Live music? Yes No
Disc Jockey? Yes No
Type of music:
20.Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No
Explain:
21.Is there any type of designated driver program? Yes No
Explain:
H.ABUSE AND MOLESTATION (if coverage is desired)
1. Do your employees and volunteers (paid and volunteer) employment application include questions
about whether the individual has ever been convicted for any crime, including sex-related or
child-abuse offenses? Yes No
If yes, what is the process for dealing with a "yes" answer?
2.(a)Does your state permit you to do criminal background checks on:
Employees? Yes No
Volunteers? Yes No
(b)If yes, do you routinely request and receive such background information on all
individuals who will have contact with minors? Yes No
3.(a)Do you verify employment-related references for employees? Yes No
(b)Do you verify employment-related references for volunteers? Yes No
4.(a)Do you conduct a personal interview for employees? Yes No
(b)Do you conduct a personal interview for volunteers? Yes No
5.Do you have a written set of procedures for screening employees and volunteers? Yes No
If yes, please forward. If no, please describe your screening process.
6.Do you have an Abuse / Molestation Policy with regard to sexual abuse? Yes No
If yes, please indicate how it is transmitted to your employees/volunteers.
7.Do you have written procedures for dealing with allegations of sexual abuse? Yes No
If yes, please forward. If no, please describe what your current response would be.
8.Describe how your organization supervises employees and volunteers having custody of children.
Describe specific policy regarding any overnight travel.
9. (a)Has your organization ever had an incident which resulted in an allegation of sexual abuse? Yes No
If yes, please describe your organization's response to the allegation.
(b)Was a claim made against the organization or an individual within the organization? Yes No
When did the alleged incident(s) occur?
(c)Was the case taken to trial? Yes No Civil Criminal
(d)What was the disposition of the case?
10.Regarding coverage for abuse and molestation, does your current insurance program:
Yes NoExclude coverage?
Yes NoLimit coverage (please forward a copy of the endorsement)?
Yes NoNeither exclude nor limit coverage?
Yes NoDoes your current insurance program include Sexual Abuse & Molestation coverage?
11.Please indicate age range of minors in your care or under the supervision of your employees or volunteers at any time.
12.Please describe your current and/or planned operations that involve the custodial care of minors.
I.CHILDCARE Yes No
If yes, please provide:
1.Is your childcare service required to be state licensed? Yes No
2.Age of children in childcare? Minimum:Maximum:
4.Ratio of adult staff/attendance to children at any given time:
5.What system do you use for checking children in and out of childcare?
7.Are any of the childcare attendants CPR and/or first aid trained? Yes No
8.Are parents allowed to leave the facility while children are in your care? Yes No
9. Is a waiver signed by a parent or guardian? Yes No
J.SWIMMING POOLS, SLIDES AND DIVING BOARDS Yes No
If yes, please provide:
1. How many swimming pools do you have?
What year was the swimming pool installed?
Do the pools/spas comply with the mandatory provision of the Federal Pool and Spa Safety Act? Yes No
Are there diving boards? Yes No
If no, are NO DIVING signs posted on pool walls and decking? Yes No
Are there waterslides? Yes No
Is the pool completely fenced and locked when not in use? Yes No
Are there lifeguards present at all times when the pool is open to the public? Yes No
If no, how is the pool area monitored?
How often is the water quality of the pool tested?
Hourly Every other hour Twice a day Daily Other:
Are testing logs kept? Yes No
Are there whirlpools/hot tubs? Yes No
If yes, how many?
If yes, is there an age restriction for use of the hot tub? Yes No
Are there proper ground fault interrupters in place for all swimming areas? Yes No
2.What is the maximum depth of the pool:
Are there clearly visible depth markers on the edging of the pool? Yes No
Is there pool lighting present and functioning? Yes No
3.Name or title of person in charge of pool operation and maintenance.
Is he/she AFO or CPO certified? Yes No
K.SAUNA/STEAMROOM Yes No
If yes, please provide:
1.Is the sauna(s)/steam room(s) monitored for usage during open hours? Yes No
If so, how frequently:
Are written logs kept when checked? Yes No
2.Are rules posted regarding the proper use and safety precautions? Yes No
3.Does the sauna(s)/steam room(s) heating elements have a protective cover to prevent burns? Yes No
L.RESTAURANT/SNACK OR JUICE BAR/VENDING Yes No
1.If yes, indicate exposure: Restaurant Snack/Juice Bar Vending
2.Are all cooking surfaces properly fire protected? Yes No
3.What type of Automatic Extinguishing System (AES) is in place?
4.Do you have a contract for servicing and maintaining the Automatic Extinguishing System? Yes No
5.How often is this system serviced and maintained? Monthly Quarterly Semi-Annually Annually
6.How often are filters cleaned?
By whom?
7.How often are hoods/ducts cleaned?
By whom?
M.TANNING Yes No
If yes, please provide:
1.Are warnings signs posted? Yes No
Are UVB bulbs used? Yes No
3.How is timing controlled and by whom?
4.Are protective eye goggles required to be worn? Yes No
5.Are the beds cleaned/disinfected between users? Yes No
6.Is tanning available to non-members? Yes No
7. What is the minimum age allowed to use a tanning device?
N.CLIMBING WALLS Yes No
If yes, please provide:
1.Provide detailed descriptions of the Rock Wall to be used (list name, description and, if possible, provide brochures, pictures or internet address):
What is the height of each wall?
How many climbing walls do you have?
2.Who sets up the rock wall? Rental Agency Insured Organization (you)
3.Where will the rock wall be set up?
4.Is the rock wall set up on flat ground? Yes No
5.Who inspects the rock wall to make sure that it is set-up correctly? Rental Agency Insured Organization
6.Hours of operation:
7.How many attendants at the rock wall?
8.Are all attendants over the age of 18? Yes No
If no, please describe:
9.Describe attendant’s responsibilities:
10.Who is the manufacturer(s) of the rock wall? Get from rental company:
11.How often is the rock wall checked and inspected? Get from rental company:
12.Does the rental company keep a maintenance or inspection log? Yes No
Risk Management/Emergency Planning
13.Explain the plan in case of an emergency:
14.Describe the plan for weather emergencies (e.g. rain and/or high winds):
15.Explain method of communication from rock wall site should an emergency arise:
16.How are weight/age limitations enforced?
17.How many people are allowed on the climbing wall at one time?
18.Will the rock wall have permanently attached warning labels and safety instructions? Yes No
19.Does rock wall provider carry $1,000,000 in GL insurance with an “A” rated carrier? Yes No
Will the provider list your organization as an additional insured? Yes No
20.Will your employees/volunteers receive formal training on the safe operation of the ride? Yes No
21.Is there an emergency plan in place and included as part of your operator training? Yes No
22.Is the wall picked up by the rental agency immediately after the rental event ends? Yes No
23.Will a liability release waiver or rental contract be signed? Yes No
If yes, please provide a copy.
24.First aid available at the event? Yes No
25.Injury/lost property disclaimer sign used at the rock wall site? Yes No
If yes, please provide verbiage or photo of sign:
26.Will the power be provided by a generator on site? Yes No
27.Has your organization had any incidents/claims relating to the use of rock wall? Yes No
If yes, please explain:
O.INFLATABLES/BOUNCE EQUIPMENT Yes No
If yes, please provide:
1.Provide detailed descriptions of the inflatable to be used (list name, description and, if possible, provide
brochures, pictures or internet address):
2.Who sets up the inflatable(s)? Rental Agency Insured Organization (you)
3.Where will the inflatable(s) be set up?
4.Is the inflatable(s) set up on flat ground? Yes No
5.Who inspects the inflatable to make sure that it is set-up correctly? Rental Agency Insured Organization
6.Hours of operation:
7.How many attendants at each ride?
8.Are all attendants over the age of 18? Yes No
If no, please describe:
9.Describe attendant’s responsibilities:
10.Who is the manufacturer(s) of the inflatable(s)? (obtain from rental company if not owned)
11.Is a maintenance or inspection log maintained by you or the rental company? Yes No
How often is the inflatable(s) checked and inspected? (obtain from rental company if not owned)
Risk Management/Emergency Planning
12.Explain the emergency plan in case of unplanned deflation:
13.Describe the plan for weather emergencies (e.g. rain and/or high winds):
14.Explain method of communication from inflatable site should an emergency arise:
15.How are weight/age limitations enforced?
16.Are riders of similar size and ability grouped together on inflatable bounces? Yes No
17.With regard to inflatable rides that allow riders to participate one at a time, what is the guideline for
letting the next participant go (e.g. large inflatable slides – one at a time participation):
18.Will the inflatable have permanently attached warning labels and safety instructions? Yes No
19.Does inflatable provider carry $1,000,000 in GL insurance with an “A” rated carrier? Yes No
Will the provider list your organization as an additional insured? Yes No
20.Will your employees/volunteers receive formal training on the safe operation of the ride? Yes No
21.Is there an emergency plan in place and included as part of your operator training? Yes No
22.Is the ride picked up by the rental agency immediately after the rental event ends? Yes No
23.Will a liability release waiver or rental contract be signed? Yes No
If yes, please provide a copy.
24.First aid available at the event? Yes No
25.Injury/lost property disclaimer sign used at the inflatable site. Yes No
If yes, please provide verbiage or photo of sign:
26.Will the power be provided by a generator on site? Yes No
27.Has your organization had any incidents/claims relating to the use of inflatable? Yes No
If yes, please explain:
P.CRYOTHERAPY CHAMBER Yes No
If yes, please provide:
1.Name of chamber manufacturer:
2.An explanation or copy of the staff training program:
3.How is the chamber operated (i.e. controlled by member/guest or staff)?
4.Is the chamber used for medical rehab or for on-demand type voluntary use?
5.Copy of waiver form being used for the chamber.
REQUIREDADDITIONAL INFORMATION NEEDED

• 5 years of currently-valued loss runs

• Copy of adult and minor waiver

• Copy of membership application

• Copy of written emergency evacuation plan

• Copy of written abuse guidelines and reporting procedures (if coverage is requested)

I hereby represent and confirm that I have read all of the questions and answers contained herein and that, to the best of my knowledge, the information is true and correct.