WELLNESS CENTRE APPLICATION

Trothen & McConkey Insurance Brokers Ltd.

Phone: 1-519-672-3224 Fax: 1-519-439-8865 Toll Free 1-888-346-6602

E-mail –

Brokerage Name:

Broker Telephone: Fax: E-mail:

Business Name:
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Location Address:
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City:
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Prov.:
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P.C.:
Mailing Address:
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City:
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Prov.:
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P.C.:
Owner/Operator:
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Bus.#:
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Fax:
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Email:
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Cell #:
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Res.#:
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Alternate Contact:

(If Applicable)

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Phone:

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Email:

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Website:

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Expiry Date of Current Policy: / Retroactive Date of Current Policy:
Current Insurance Company:
Number of years in business? / Have you ever been cancelled for nonpayment? / YesNo

PROPERTY INFORMATION

Describe your location (strip plaza, shopping mall, etc.):
Building Age (year built): / No. Of Stories: / Do you own the building?
Total Area of Building: sq. ft. / Total Area of your Facility: sq. ft.
Sprinkler System: / Monitored Alarm: / Fire Hydrants within 500 feet:
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) / If yes, please describe:

CONSTRUCTION OF BUILDING

F/R / Structures/buildings must be made of reinforced concrete or protected steel / N/C / 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
Masonry / brick veneer & combination of steel, concrete and wood / Frame / wood, tar and brick or similar materials.
LATEST UPDATES / FULL / PARTIAL / YEAR COMPLETED / TO CODE
Roof: / YESNO
Heat: / YESNO
Plumbing: / YESNO
Electrical: / YESNO


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

STOCK: / Clothing / $ / Supplements / $ / Other / $
EQUIPMENT: / Computers / $ / Laptops / $ / Signs / $
Furniture / $ / Machines / $ / Other / $
LEASEHOLDS: / Existing Tenants Improv. / $ / Change Rooms / $ / Offices / $
Washrooms/Showers / $ / Phone/Alarm Sys. / $ / Construction / $
Wall Coverings/Flooring / $ / Built-in Units / $ / Other / $

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

BUILDING REPLACEMENT VALUE (if required) (sq.ft. of building x cost/sq.ft. $) = $

OTHER BUSINESS(ES)

Do you own/operate or rent space to other businesses? / YesNo / Total annual rental income $
Describe type(s) of business:

EQUIPMENT

Do You Have Modified/Rebuilt/Used Equipment?

/ /

If Yes, % used: %

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Age:

Is Equipment Inspected Daily? YesNo

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Who Does Maintenance?

LIABILITY INFORMATION

Liability Limit Requested: $2,000,000 $3,000,000 $4,000,000 $5,000,000

DESCRIPTION OF OPERATIONS

Any clients under the age of 18? / YesNo / Do parents stay on premise? / YesNo
Are any operations or activities done away off premises? / YesNo / Describe:
Do you sell any metabolic supplements? / YesNo

WET AREAS

Showers / # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 / Whirlpools / # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 / Steam Rooms / # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Hydrotherapy Tubs / # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 / Vichy Showers / # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 / Infra Red Saunas / # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Dry Saunas / # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 / Wet Saunas / # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 / Pools / # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Are all steam rooms vents/spouts covered/capped to defuse the steam? / YesNo
Any scorching behind heater? / YesNo / Non-Slip Flooring? / YesNo / Rubber Mats In Halls? / YesNo

EMPLOYEES - INCL. OWNER/OPERATORS (attach another page if necessary)

Name / Yrs of
Exp. / Operations Performed / Has a Current Professional Liability Policy
Y / N / F/T or P/T
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
SUB-CONTRACTORS (attach another page if necessary)
Name / Yrs of
Exp. / Operations Performed / Has a Current Professional Liability Policy
Y / N / F/T or P/T
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
MEDICAL SPECIALIST (attach another page if necessary)
Name / Yrs of
Exp. / Operations Performed / Has a Current Professional Liability Policy
Y / N / F/T or P/T
YesNo
YesNo
YesNo
YesNo
Is all staff certified/educated/trained in the services they perform? / YesNo
Are all staff licensed and carry at least $1MIL in Professional Liability? / YesNo
If no, please advise why:

SERVICES

TOTAL ANNUAL GROSS RECEIPTS - $
ORDINARY MONTHLY PAYROLL - $

PRIMARY SERVICE(S)

PHYSIOTHERAPY / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15% / RMT / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15%
SPORTS/ATHLETIC THERAPY / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15% / STRESS MANAGEMENT / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15%
CHIROPRACTIC / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15% / ACUPUNCTURE / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15%
OTHER - / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15% / OTHER - / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15%

OTHER SERVICES OFFERED

Acupressure / Acupuncture / Alexander Technique / Amatsu Medicine
Aromatherapy / Aurora Healing / Autogenic / Aqua Chi
Aura Soma Colour Healing / Ayurveda / Bi-Aura Therapy / Bach Remedies
Bates Method / Behavioral Analysis / Bio-Chemics / Biocom therapy
Bio-Kinetics / Boresonance / Body Harmony / Body Mind Balancing
Bowen Technique / Chakra Balancing / Colour Therapy / Conscious Breathing
Colour Puncture / Cranial Sacral Therapy / Crystal Healing / Cymatic
Dance Movement / Deep Oscillation Therapy / Dietician / Drama Therapy
Dowsing for Stress Relief / Electro-Crystal therapy / Electronic Therapy / EMF Balancing Technique
Emotional Therapy / Facilitation / First Aid Trainer / Healing Touch
Hellerwork / Hot Stone Therapy / Hydrotherapy / Hypnotherapy
Homeopathy / Iridology / Infant Massage / Indonesian Massage
Jungian Therapy / Kairos Therapy / Kinesiology / Life Coaching
Light Touch Therapy / Lymphatic Drainage / Lomi Lomi / Magnetic Therapy
Manual Lymph Drainage / Massage Therapy / Meditation / Metamorphic Technique
Melchizedek Method / Mezieres Method / Moxibustion / Movements Therapy
Muscle Energy Techniques / Myofacia / Occupational Therapist / Ohashiatsu
Orthotics / Perceptible Breath Therapy / Personal Care / Physical Therapy
Phytotherapy / Pilates / Polarity Therapy / Postural Integration
Phytobiophysics / Pranic Healing / Qi Gong / Radiaesthesia
Radionics / Raynor Therapy / Reality Therapy / Rebirthing - Breath Techniques
Reflexology / Reiki / Rolfing / Rubenfeld Synergy
Shen Therapy / Skenar / Skeletal Balancing / Skin Screening
Somatic Movement / Speech Therapy / Spiritual Healing / Stress Control/Management
Tai Chi / Thai Massage / Therapeutic Touch / Trager
Trigger Point Massage / Tuina / Vega Machine / Vibrational Essences
Watsu / Yoga / Zero Balancing / Zen Therapy
Other: *LIST ANY& ALL OTHER SERVICES THE CENTRE PROVIDES

CRIME – Answer Yes or No to Each Question

Cash Accounts and inventories have annual (minimum) audits by a certified auditor or accountant. / YesNo
Reconciliation of bank statements are handled by someone other than those who have authority to handle deposits, withdrawals or sign outgoing cheques. / YesNo
Bank accounts are reconciled on a monthly basis (minimum). / YesNo
Background checks are completed on all employees that handle money. / YesNo
All cheques over $5,000 must require 2 signatures, unless only the owner(s) has authority. / YesNo

ADDITIONS TO THE POLICY

ADDITIONAL INSURED

(i.e.: landlord)

LOSS PAYEES

(i.e.: financing, leases, etc.)

CLAIMS HISTORY

Has the company &/or staff had claims against them in last 5 years? , If yes please list details:

Date of Loss / Loss Details / Amount Paid/Reserve
$
$
$

I understand and agree that any policy issued will be based upon the information contained in the application and any related forms. I understand that any formsor 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: Signature: Title: Date:

Wellness Centre Application Page 4 of 4