Insurance: Business: Application

Business Information

• Legal Business Name
• Doing Business As
• Type of Business: Corporation
  LLC
  Individual
  Partnership
  Other
• Business Owner's Name
• Tax ID Number
• Year Business Started

• ***If less than 3 years Ownership or Experience, please send us a brief resume**

  The following file extensions are accepted: *.pdf, *.doc, or *.txt
• Mailing Street Address
• City
• State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Zip
• Website Address
• Please Select the statement that best describes your application submission.
  I am Renewing my policy I am a new applicant with SIS
• Requested effective date
• This strictly a mobile or Tumblebus business
• Click here if location is different than the mailing address address. Must be listed in order to be an insured location
• • Insured Property Location
  • Location Street Address
  • City
  • State -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
  • Zip
  • I own this property
    I lease this property

• Contact Information

• 1. Work
  2. Cell
  3. Home
  4. Fax
• Main Contact Name
• Main Contact Position
• Main Contact's Email

Prior Insurance Information

• Current Liability Company
• Policy Expiration Date
• Current Premium

• Injury & Claim Information

• Have you had an injury that resulted in a claim with your previous liability company in the last 3 years?
  
  Yes No
  
  

  Please complete the following information about the previous injury or accident(s) your business has experienced.

  • Injury / Accident
  • Date of Claim
  • Amount Paid Out
  • Description of Injury or Incident

• Certificate Holder Requests / Additional Insureds

• Check this box if you need to name an additional insured or send proof of Liability insurance to anyone.

• This usually includes your landlord, facilities that you teach at, competitions or events that you attend. (Once you are a client of SIS you can make additional certificate requests on the Client Services page)

  • Additional Insured
  • Name
  • Address
  • City
  • State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
  • Zip
  • Is this for a/an (select one) Landlord Mortgage Company Event
  • Event Dates: To
  • Does this certificate require the holder to be listed as a Additional Insured: Yes No
    
    Does this certificate require the holder to be listed as a Loss Payee: Yes No

• General Activites Questions

• 1. What are your estimated annual gross receipts?
  2. Are liability waivers obtained from all participants including parent in facility fo Mommy and Me or Parent/Tot Classes and Parties?
     Yes No
  3. Do you have a written Safety Program including procedures and rules concerning all activities?
     Yes No
  4. Do you keep a record of regularly scheduled equipment maintenance and an inspection checklist?
     Yes No
  5. Do you obtain criminal background checks on all primary coaches and volunteers?
     Yes No
  6. Is the ration of students to instructors for your overall activities 10:1 or less?
     Yes No
  7. Do you have any trampolines or other tumbling devices with rules posted for usage?
     Yes No
  8. Do you have written rules of conduct and regulations for membership into your business?
     Yes No
  9. Has any policy or coverage been declined, cancelled or non-renewed in last 3 years?
     Yes No
     
     Please provide a brief detailed explanation
     
  10. Do you rent space to anyone for any reason including teaching students that are not your members?
      Yes No
      * If Yes they must provide you with a Certificate of Insurance listing your business as an Additional Insured and the insurance Liability Limits must be equal or greater than yours.
  11. Do you offer licensed Day Care services?
      Yes No
      
      A separate policy may be required
      Day Care License Number
      
  12. Do you offer Parents Day Out or Open Gym?
      Yes No
      
      Please explain activities and supervision
  13. Do you have an evacuation plan with exits clearly posted?
      Yes No
  14. Do you have a retail store on premises?
      Yes No
      
      What are your annual sales receipts?
  15. Do you have a booster club?
      Yes No
      
      List activities performed by Booster Club
      
      
      Is the booster club a separate legal entity
      Yes No
  16. Do you share over 50% common ownership of the Booster Club? You may include it as an additional named insured for an annual charge of $175.00. If you would like this coverage, enter the legal name of the Booster Club to be insured
      
  17. Does your facility have Rock Walls?
      Yes No
      
      What is the height of your walls? Seperate each wall's height with commas*Harness and helmets required for walls over 10 feet
      
      
      Are any of your rock wall(s) portable and removed from the premises at any time?
      Yes No
  18. Does your facility have a Zip Line?
      Yes No
      
      What is the height and length?
      
  19. Do you own/operate any inflatable amusement devices (not including inflatable training equipment and air tracks)?
      Yes No
      
      How many?
      
      List name of each inflatable
      
  20. Does your facility have any "Soft Play" equipment such as climbing tubes or ball pits?
      Yes No
  21. Does your facility have a Foam Pit?
      Yes No
      
      Are sides padded?
      Yes No
      
      Side depth:
      
      Type of padding
      (ex: foam blocks)

• AVERAGE monthly student enrollment calculator

• You will need to calculate your average monthly number of students for each activity. Here's how: Count each participant only 1 time each month regardless of how many times they come to your facility in a month.

  Jan

  Feb

  Mar

  Apr

  May

  Jun

  Jul

  Aug

  Sept

  Oct

  Nov

  Dec

  
  

  0 average participants per month

  
  

• Average Monthly Participant Activities

• Team & Non Team Class Participation	18 & Younger	19 & Older
  Cheerleading: Non-Competitive
  Cheerleading: Competitive
  Gymnastics: also include Preschool Gymnastics, Tumbling, Arts/Crafts, Music No one over 22 on equipment!
  Dance
  Aerobics, Fitness, or Rhythmic Floor Exercise / Motor Skills
  Tumblebus(Mobile Program) (only record child, not parent)
  Mommy & Me (only record child, not parent)
  Martial Arts
  Swimming (additional questions are required below)
  Before / After School Drop Off kids that do not participate in any activity above
  Other (additional questions are required below)
  SubTotal Monthly Participation in Activites
  Total Monthly Participation in Activites (should total number of average monthly partcipiants)

• Average Monthly Participant Ages

• Studen Ages	# of Team Students	# of NON-Team Students
  12 & Under
  13 - 15
  16 - 18
  19 & Above
  SubTotal TEAM and NON-TEAM
  Total TEAM and NON-TEAM

• Swimming Activities

  1. How many months out of the year is the pool open?
     
  2. Where is the pool located at that is used?
     
  3. What are the hours of operation for the pool?
     
  4. What type of pool is used? (ex: indoor, in ground or outdoor, above ground etc.)
     
  5. What are the dimentions of the pool? (ex: indoor, in ground or outdoor, above ground etc.)
     
     1. Length
     2. Width
     3. Minimum Depth
     4. Maximum Depth
  6. How would you descripbe the Water Clarity?
     Good Fair Poor
  7. What is the condition of the pool?
     Good Fair Poor
  8. Does the public have access to the pool?
     Yes No
  9. Are lifeguards on duty during all hours of operation?
     Yes No
     
     Total number of lifeguards
  10. Does the pool have diving boards?
      Yes No
      
      
      1. What is the height for each diving board?
         
      2. Do they have handrails?
         Yes No
      3. Do they have a slip resistant surface?
         Yes No
  11. Is there a waterslide?
      Yes No
      
      Please describe height and type of slide
  12. Does the pool have 2 entrances into the water, one at each end consisting of ladders or stairs?
      Yes No
  13. Do all stairs leading into the pool have at least one handrail and all ladders at least 2 handrails?
      Yes No
  14. Are depth measurements plainly and conspicuously marked at or above the waterline?
      Yes No
  15. Are minimum and maximum depths and all points of slope change marked?
      Yes No
  16. Is the following safety equipment conspicuously and conveniently on hand at all times?
      
      1. Have a safety pole not less than 12 feet including a 'Life or Shepards Hook' Yes No
      2. Have a throwing rope at least 50 feet long and attached to a ring buoy Yes No
      3. Have a telephone with 911 clearly shown Yes No
  17. Is the perimeter of the pool completely protected by a fence at least 4feet in height?
      Yes No
  18. Are all gates self-closing and have self-latching mechanisms at least 45inches above the ground?
      Yes No
  19. Does the pool have in-pool lighting or light of sufficient strength to illuminate the bottom?
      Yes No
  20. Is eating and drinking allowed in the pool area?
      Yes No
  21. Are rules for using the pool posted?
      Yes No
      
      Please describe signs and where posted
  22. Is an analysis of the pool's temperature and chemical makeup made and recorded daily?
      Yes No

• Martial Arts

  1. Please specify / describe the type of martial arts:
     

• Other

  1. Please describe the Events or Activites that involve your facility:
     

• Events, Competitions and Recitals

  Does your facility host non-sanctioned dance competitions or recitals?
  (Recitals that you produce for no entry fee [such as recitals for family & friends] are covered for no additional fee and do not need to be listed. Answer yes only if your business charges a fee for admittance to an event hosted by your business)
  Yes No
  • 
    
    Event
  • Event Type
    Event Competition Recital
  • Activity that best matches your event, competition, or recital
    Gymnastics Cheer Dance Other
  • Event Start and Ending Dates including rehearsals
    
  • Are any Sub-contractors providing any service for this event
    Yes No
  • Address of Event
    
  • Is there an entrance fee?
    Yes No
  • Is this event sanctioned, or non-sanctioned?
    Sanctioned Non-Sanctioned
    
    
    Number of days per year you host events?
    
  • Average per event day participants ages 18 & under
    
    Average per event day Participants ages 19 & over
  • Total number of Staff & Volunteers
    

• Parties & Hosted Events

• My facility offerers parties.
• 1. How many parties do you host a year?
     
  2. If your facility includes a rock wall are the Party attendees allowed on it?
     Yes No
  3. Do you have any type of inflatable or mechanical amusement device used by Party attendees?
     Yes No
     
     Please list devices:
     
  4. Are parents or siblings of Attendees allowed on any devices?
     Yes No
  5. Is every attendee including parents and siblings required to sign a Liability waiver?
     Yes No
  6. What is the ratio of Staff Members to attendees?
     
  7. Briefly explain the type of activities normally offered at a party and equipment used:
     

• Overnight Activity Questions

• My facility offerers overnight activities.
• 1. Describe all activities offered for overnights:
     
  2. Are any activities unsupervised?
     Yes No
     
     Please explain all unsupervised activities:
     
  3. Is at least 1 person over the age of 25 years on-site all night?
     Yes No
  4. Is there any water-related activity or water hazard?
     Yes No
     
     Please explain water-related activities
     
  5. Do you have any special needs participants?
     Yes No
  6. Are the overnight activities co-ed?
     Yes No
  7. Director's number of years overnight activity experience
     years
  8. What is the ratio of staff to participants?
     
  9. Describe sleeping arrangements:
     
  10. Describe physical characteristics of facility for overnight:
      
  11. Details of each staff's training for overnight activities:
      

• Summer and/or Day Camps

• My facility is involved with summer camps and/or day camps.
• 1. Annual number of camp days.
     
     
     Annual number of campers per day that aren't regular students.
     

• Sexual Abuse and Molestation

• Sexual abuse and Molestation coverage will be included if all following questions are answered "Yes".
  
  If any of the questions are answered "No", Sexual Abuse and Molestation coverage will be excluded.
  
  
• 1. Does your business have and enforce written standards regarding Sexual Abuse & Molestation?
     Yes No
  2. Does your employment application for your staff and volunteers include questions about whether they have ever been convicted for any crime including sex-related or child abuse related offenses?
     Yes No
  3. Does your state permit you to do criminal background checks on prospective employees and/or volunteers?
     Yes No
     
     Do you routinely request and receive such background checks?
     Yes No
  4. During your staff orientation do you discuss child/sexual abuse including how to recognize the signs and what to do if a staff personnel, child or volunteer reports someone molested him/her and document it?
     Yes No
  5. Do you have a crisis management plan for dealing with staff personnel, including volunteers, victims, parents, authorities and media if you have an incident of abuse?
     Yes No

Application Release Agreement

THE AUTHORIZED OFFICER OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE AUTHORIZED OFFICER AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (THE AUTHORIZED OFFICER) WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF.

The undersigned authorized officer of the Applicant acknowledges that he/she is aware that the limit of liability contained in this policy shall be reduced, and may be completely exhausted, by the costs of legal defense or for the amount of any judgment or settlement to the extent that such exceeds the limit of liability of this policy.

The SUBMITTING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE. By submitting this application, the authorized officers of the Applicant hereby further acknowledges that he/she is aware that legal defense costs that are incurred shall be applied against the retention amount.

Fraud Warning(s) NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

• Have you read and understood the application release agreement above?
  Yes No
• Please enter your name to submit.
  
• Please enter your title to submit.
  
•