ICE RINK SUPPLEMENTAL QUESTIONNAIRE
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NOTE:
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This questionnaire is to be submitted along with the following completed forms:
ACORD Applicant Information application 125
ACORD Commercial General Liability Section 126
ACORD Applications for other requested coverages: Property; Garage; Crime; Inland Marine;
Transportation; Excess Liability; Employment Related Practices.
Supplemental forms (Abuse; EBL; NOHA; Liquor; Inflatables) as applicable.
GENERAL INFORMATION
Rink Name (DBA):
Address:
Corporate Name:
Insured’s FEIN number?
Insured’s website address?
UNDERWRITING INFORMATION
Do you own or lease the premises?
Own
If leased, what are the other occupancies/tenants in the building, if any?
Lease
List ice rink associations of which you are a member: ISI
If Others, which one(s)?
NEISMA
Is this a new operation?
Yes
STAR
Others
No
Number years in business at this location (operated by you):
List other locations owned or operated:
Do you run programs in your rink under another business name?
IF SO, PLEASE PROVIDE NAME(S):
Yes
Do you conduct any other business under the named insured on this application?
IF SO, PLEASE DESCRIBE:
Form No. ICERINK (01/17)
Page 1 of 6
No
Yes
No
SP # 7337588
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and
A S Insurance & Risk Services Agency. All rights reserved.
Annual Gross Receipts Breakdown:
Receipts in U.S. dollars
(If N/A please indicate)
General Admissions
Open Public Skating
Skate Rental
Waiver/disclaimer used on ticket? (If yes,
provide copy) Yes
No
Open Public Hockey
Rink Sponsored Events
Waiver/disclaimer used on ticket? (If yes,
provide copy) Yes
No
Ticket Sales to
Spectators
Are participants members of: USFSA
ISI
Figure Skating
Do you collect certificates of insurance from
instructors?
Yes
No
Do Participants sign individual waivers? Yes
Are participants members of: USFSA
No
ISI
Learn to Skate
Do you collect certificates of insurance from
instructors?
Yes
No
Do Participants sign individual waivers? Yes
Are participants members of: USAH
Beginners’ Hockey
No
ISI
Do you collect certificates of insurance from
instructors?
Yes
No
Do Participants sign individual waivers? Yes
No
Are participants members of: NGB
ISI
USAH
USFSA
Other: Camps / Clinics
Do you collect certificates of insurance from
instructors?
Yes
No
Do Participants sign individual waivers? Yes
Form No. ICERINK (01/17)
Page 2 of 6
No
SP # 7337588
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and
A S Insurance & Risk Services Agency. All rights reserved.
Ice Rental – Insured Groups
Are participants members of: USAH
ISI
Do you collect certificates of insurance? Yes
No
Do Participants sign individual waivers? Yes
No
Youth Hockey
Are participants members of: USAH
Junior Hockey
High School, College,
Junior
ISI
Do you collect certificates of insurance? Yes
No
Do Participants sign individual waivers? Yes
No
Other Revenue
Pro Shop
Skate Sharpening
Snack Bar, Vending,
Restaurant
Liquor Sales
(If Any)
Long term leases
(tenants)
Advertising
$
rent
Leased space
ft.
Do you operate?
If leased, do you collect certificate of insurance?
Do you operate?
If leased, do you collect certificate of insurance?
Do you operate?
If leased, do you collect certificate of insurance?
Do you operate?
If leased, do you collect certificate of insurance?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Do you collect certificate(s) of insurance?
Yes
No
Sq.
Other – please
indicate
Total Revenue –
All Sources
PHYSICAL PLANT AND MAINTENANCE INFORMATION
Number of stories:
Total square footage:
# of Skating surfaces:
Length:
x Width:
Height of boards:
Height of glass at sides:
Protective netting?
Yes
No
Full
Surface Composition under ice:
Type of other floor surfaces:
Date these were last resurfaced:
Condition:
Is the rink:
Indoor
Outdoor
If outdoor:
Describe how you monitor ice quality:
Describe how you secure rink when closed:
Age of building:
If over 25 years old, year updated: Electrical:
Do you have any spectator seating?
Yes
No Maximum Seating?
Type of Construction:
Age:
Do you have the following: (If yes, please attach copies for underwriting)
Rink Rules Posted?
Yes
No
Form No. ICERINK (01/17)
Page 3 of 6
=
SQ FT
Height of at ends:
Ends
Other
HVAC:
SP # 7337588
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and
A S Insurance & Risk Services Agency. All rights reserved.
Skaters’ Code of Conduct posted?
Written Emergency Plan(s)?
Safety Inspection Checklist
Skate Maintenance Log?
Ice Resurfacing Log?
Video Surveillance?
Describe areas of coverage for video surveillance:
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Please describe regular maintenance on rink:
Do you document this maintenance in writing?
Yes
No If yes, describe:
Have you installed a fire alarm?
Yes
No
Have you installed a burglar alarm/motion detector?
Yes
No
Do you have outside security?
Yes
No
If so, how many?
Are they armed?
Yes
No
Do you have certified first aid personnel?
Yes
No
CPR
First Aid
Number per session:
Do you have an AED?
Yes
No Number of personnel trained to use:
Do you have a deep fryer or a grill?
Yes
No
If yes, is it approved by the Fire Marshall?
Yes
No
How often is the system cleaned?
Name of service contractor:
Maximum occupancy rate:
per fire code
ICE RESURFACING EQUIPMENT:
Year
Make
RC Value
Fuel Source
1.
2.
AIR QUALITY (Gasoline & Propane Equipment)
Is ice resurfacer (zamboni) regularly maintained?
Please describe:
Yes
Does rink have carbon monoxide testing equipment?
Hand Held
Hard Wired
Portable
No
Yes
No
How often is air quality tested?
Does rink have a written policy / procedure in place in the event emissions exceed permissible levels?
Has the rink ever had an air sickness incident?
Please provide details:
Form No. ICERINK (01/17)
Page 4 of 6
Yes
Yes
No
No
SP # 7337588
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and
A S Insurance & Risk Services Agency. All rights reserved.
RINK USE INFORMATION
Do you obtain waivers specific to your facility for ALL participants in athletic activities (including dry floor activities and
activities sponsored by other organizations)?
Yes
No
Maximum # of skaters per skate guard:
Do you have special programs?
If yes, please describe:
Maximum capacity of rink:
Yes
No
Do you have banquets or dances?
If yes, please describe:
Yes
No
Do have skating competitions?
If yes, are there sponsoring or sanctioning organizations?
If yes, please provide names:
Yes
Yes
No
No
Do you have any of the following or conduct the following on your premises?
Travel Hockey
Yes
No
In-House Leagues
Yes
No
Other events off your premises
Yes
No
If yes, describe:
Speed Skating
Yes
No
Broomball
Yes
No
Roller Skating – In-line
Yes
No
Roller Skating - Quads
Yes
Exercise/Dance
Yes
No
Equipment Sales
Yes
No
Equipment Rental
Yes
No Equipment is rented for use:
On Premises
Equipment Repair
Yes
No
Day Care
Yes
No
Laser Tag
Yes
No
Bus, car or transportation service
Yes
No
Sale of alcohol
Yes
No
Fitness Center
Yes
No
Soccer or other sports
Yes
No
Dry floor events
Yes
No
If so, describe:
Other Activities
Yes
No
If other, please explain:
No
Outside of rink
STAFFING INFORMATION
Total number of staff:
Minimum age of skate guards:
Full time (40 hours):
Part time:
Owner’s name:
Manager’s name:
Years Experience:
Years Experience:
Has your staff taken any continuing education courses?
If so, who? (Name(s) & Title(s))
Yes
No
Name of course(s):
Sponsoring Organization(s)?
Form No. ICERINK (01/17)
Page 5 of 6
SP # 7337588
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and
A S Insurance & Risk Services Agency. All rights reserved.
Date(s) taken:
Are instructors/coaches:
Employees
Independent Contractors (If so, attach contract)
Do you have volunteers working for you?
Yes
No
IF SO, PLEASE DESCRIBE:
PLEASE PROVIDE THE FOLLOWING WITH THIS APPLICATION:
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Copy of carrier loss runs for the past five years
Copy(ies) of Instructors’ Certificate of Insurance
Copy(ies) of Contract Rentals’ Certificate of Insurance
Copy(ies) of Waiver(s) Used (minor and adult)
Copy(ies) of Tenants’ Lease or Contracts with subcontractors
ACORD Applicant Information application 125
ACORD Commercial General Liability Section 126
ACORD Applications for other requested coverages: Property; Garage; Crime; Inland Marine; Transportation;
Excess Liability; Employment Related Practices.
Abuse Supplemental (if applicable)
EBL Supplemental (if applicable)
NOHA Supplemental (if applicable)
Liquor Supplemental (if applicable)
Inflatables Supplemental (if applicable)
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.
I further acknowledge that I understand that this information is provided in conjunction with and in addition to the ACORD
application(s) referenced above and that the information contained herein is subject to the same notices, disclaimers,
warranties, and representations as on the referenced application(s).
Date
Signature of Insured or Authorized Representative
Title
Send completed form along with referenced ACORD application(s) to:
American Specialty Insurance & Risk Services, Inc.
7609 W. Jefferson Blvd.
Suite 100
Fort Wayne, IN 46804
Phone: (800) 245-2744
E-mail: [email protected]
Form No. ICERINK (01/17)
Page 6 of 6
SP # 7337588
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and
A S Insurance & Risk Services Agency. All rights reserved.