Golf & Country Club Application
To accurately and promptly process your application, please complete and include each
of the following with your submission:
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Completed new business application
Statement of values worksheet
Four-year hard copy of loss runs, plus current year,
for each coverage line to be quoted
Most recent audited financials or income and
expense statement
Replacement cost schedule of club’s maintenance equipment
Completed applications may be submitted to the fax or email shown below.
If you have any questions regarding any part
of this application, please contact:
SPORTS INSURANCE SPECIALISTS, LLC
4115 Clubview Dr.
Fort Wayne, IN 46804
PHONE: 260.969.0305
FREE: 855.969.0305
FAX: 260.459.1630
[email protected]
Thank you!
SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630
Golf & Country Club Application:
New Business Questionnaire
1
CLUB NAME:FEIN #:
MAILING ADDRESS:
CITY:COUNTY:STATE:ZIP:
LOCATION:
Same as mailing address.
If different, please provide location address:
ANY ADDITIONAL LOCATIONS? Yes
No
If yes, please complete a separate questionnaire for each location.
MANAGER or CLUB CONTACT:
PHONE: FAX:EMAIL:
OWNERSHIP:
Member owned (i.e. equity, proprietary)
City/Municipality owned
Individual, privately ownedResort
CorporationOther, please describe:
Partnership
CLUB STATUS:
PrivateSemi-Private (membership available*)
Daily Fee
Homeowners Association
Property Owners Association
TennisCityResort
* Explain membership privileges:
* Number of members:
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ALL SECTIONS FOLLOWING MUST BE COMPLETED IN FULL
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SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630
Golf & Country Club Application:
New Business Questionnaire
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1.
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ALL SECTIONS BELOW MUST BE COMPLETED IN FULL
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MAIN CLUBHOUSE
Type of Construction:Square Footage:Year Built:
Number of Levels:
If more than 10 years old, what years were each of the following updated?
ELECTRICAL:ROOF:PLUMBING:HVAC:
Does the Club have:
CENTRAL STATION HARD-WIRED HEAT and SMOKE DETECTION SYSTEM?
YES
NO
SPRINKLER SYSTEMYESNO
AUTOMATIC EXTINGUISHING SYSTEM INSTALLED to protect hoods, ducts, and all cooking surfaces
including deep fat fryers?YESNO
If Yes, is there a cleaning service?YESNO
If Yes, how often?
Does the system have a manual release away from the cooking area? YES
NO
OTHER SAFETY SYSTEMS? Please descirbe:
Is the Main Clubhouse closed during the off-season?
YES
NO
If Yes, for how long?
What security is provided while the Clubhouse is closed?
Does the Club have a Property Appraisal?YESNO
If Yes, please attach a copy.
Does the Club plan to host professional or major amateur events in the next year?
YES
NO
If Yes, please describe:
2.
GOLF
Number of courses:
Number of holes:
Number of rounds played annually:
Driving range? YESNO
Number of carts:Number owned:Number leased:
Powered by:GASELECTRIC
If carts are leased, is the Club named on a Certificate of Insurance as additional insured? YES
NO
Who is responsible for golf cart maintenance?
CLUB
PRO
LESSOR
Who is responsible for golf cart insurance?
CLUB
PRO
LESSOR
Are there cart operators under the age of 18?
YES
NO
If Yes, please explain:
Name of Golf Professional:
INDEPENDENT CONTRACTORCLUB EMPLOYEE
If Independent Contractor, is the Club named on a Certificate of Insurance as additional insured?
YESNO
The Pro Shop is owned by:CLUBINDEPENDENTLY OPERATED
If Independent Contractor, is the Club named on a Certificate of Insurance as additional insured?
YESNO
SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630
2
Golf & Country Club Application:
New Business Questionnaire
3
The Bailee for members’ golf clubs is:
Total value of members’ golf clubs stored at the Club?
CLUB
$
Are there any plans to renovate the golf course, buildings, or
make major capital purchase(s) during the next policy period?
If Yes, explain in detail, using and attaching a separate sheet if necessary:
3.
PRO
YES
NO
TENNIS
Number of outdoor courts:
Number of indoor courts:
Are outdoor courts lighted for nighttime play?
YES
NO
Are there tennis bubbles?YESNO
If Yes, an SIS Sports Bubble Questionnaire must be completed and submitted.
NOTE: Bubble manufacturer’s specifications must be included with submission.
Name of Tennis Professional:
INDEPENDENT CONTRACTORCLUB EMPLOYEE
If Independent Contractor, is the Club named on a Certificate of Insurance as additional insured?
YESNO
The Tennis Shop is owned by:CLUBINDEPENDENTLY OPERATED
If Independent Contractor, is the Club named on a Certificate of Insurance as additional insured?
YESNO
4.
PLATFORM TENNIS
Number of platform courts:
Type of construction:
Are outdoor courts lighted for nighttime play?
YES
NO
Are the tennis courts heated?YESNO
If Yes, powered by:GASELECTRIC
5.
SWIMMING
Check all that apply:
POOLKIDDIE POOLLAKEPONDOCEAN
Are all pools and spas compliant with Virginia Graeme Baker Pool & Spa Safety Act?
If No, please explain and provide accurate timeline:
Number of certified lifeguards:
Hours of operation:
Minimum number of lifeguards on duty during hours of operation?
Are lifeguards required to be on duty whenever the pool is being used?
If No, please explain:
YES
NO
YES
NO
SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630
Golf & Country Club Application:
New Business Questionnaire
4
Who is the pool operation manager?
Years of experience at the Club?
Years of experience managing an aquatic facility?
Is this person(s) certified to operate aquatic operations?
YES
NO
Please indicate additional activities that are scheduled to occur in the pool area:
Swim / Dive CompetitionsYESNO
Pool PartiesYESNO
If Yes, how many and what type?
Special Events or other activitiesYESNO
If Yes, please describe:
Is the pool fenced or protected by preimeter protection at least 4-feet high?
YES
NO
Does the pool fence have self-closing gates?YESNO
Are pool rules posted?YESNO
Number of diving boards:Heights:
Pool depth in diving areas:
Is the area clearly marked?
YES
NO
Number of water slides:
Describe heights and how used:
PLEASE INCLUDE A PHOTO OF SLIDE(S).
6.
WATERCRAFT
NOTE: The following watercraft are NOT eligible for this program:
• Powerboats over 50 HP
• Sailboats of 26 feet or more
Number of owned watercraft:
CanoesRowboatsKayaks
Powerboats 50HP or lower
Sailboats 26’ and under Other:
Are any watercraft used by club members?YESNO
If Yes, please describe and provide quantity:
7.
PLAYGROUND
Does the Club have a playground?YESNO
If Yes, please describe:
Is the playground protected by perimeter fencing at least 4-feet high?
Does the playground fence have a self-closing gate?
YES
YES
NO
NO
SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630
Golf & Country Club Application:
New Business Questionnaire
8.
5
OTHER CLUB ACTIVITIES
Check all that apply:
Skeet / Trap RangesSnowmobilingJacuzzi / Saunas
Saddle AnimalsCross-country SkiingSteam Room
HuntingDownhill SkiingTanning Beds
FishingBarbershop / Beauty ParlorFitness Trainer
Ice Skating
Masseur / Masseuse
Day / Summer Camps **
Sledding
Health Club Facilities / Spa*
Babysitting / Child Care**
* Exercise Questionnaire must be completed and submitted.
** Babysitting / Day Care / Day Camp Questionnaire must be completed and submitted. Briefly describe any activities not listed above:
9.
OVERNIGHT EXPOSURES
Are there any overnight accommodations?YESNO
If Yes, are the overnight facilities for member and their guests?
YES
NO
If Yes, please indicate the number of rooms / apartments available:
Are there overnight facilities open to the public?
YES
NO
Are there overnight facilities for employees?YESNO
If Yes, please indicate the number of resident employees:
10.
JUNIOR PROGRAM
List any Junior Program sports:
Do Junior teams travel to other clubs?YESNO
If Yes, how are children transported and supervised?
11.
OTHER
Approximate number of Weddings, Banquets, Parties, and Special Events annually:
Approximate number of Members / Guests / Public who attend:
On contracted work, is the Club listed as additional insured on Certificates of Insurance? YES
Are the Club’s facilities loaned or rented to non-member organizations?
YES
If Yes, please describe:
12.
NO
NO
CRIME / CHECK SIGNING PROCEDURES
Are checks over $2,500 countersigned?
If No, please explain:
Does the Club handle:
CASH TRANSACTIONS ONLY
Does the Club require member account numbers on all transactions?
Does the Club offer any credit charge facilities outside of member account charges?
Do special events bring in unusually large sums of cash?
If Yes, please explain:
YES
NO
MEMBER CHARGES ONLY
YES
NO
YES
NO
YES
NO
SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630
Golf & Country Club Application:
New Business Questionnaire
13.
6
RESTAURANT AND/OR SNACK BAR
Operated by:CLUBCONCESSIONAIRE
If Concessionaire, is the Club listed as additional insured on a Certificate of Insurance?
YES
NO
Gross liquor receipts (excluding non-alcoholic beverages):
Restaurant receipts:
Club’s liquor license is in the name of:
Bar and Liquor exposures:
Have all bartenders attended a course on Dram Shop LIability (TIPS)?
YES
NO
Is this an on-going training program?YESNO
Is there formal training on service to intoxicated patrons?
YES
NO
What hours are alcoholic beverages served?
Does the Club have a dance floor and offer live entertainment?
YES
NO
If Yes, please describe:
14.
VALET PARKING
Does the Club provide valet parking?YESNO
If Yes, services are provided by:
Club Employees Contracted Services
If Contracted, is the Club listed as additional insured on a Certificate of Insurance? YES
NO
15.
COASTAL PROPERTIES (Must be completed by Clubs in coastal areas)
Age of roof on main building:
Does the roof meet current State Codes?YESNO
Do you have a hurricane preparedness program?
YES
NO
If Yes, please attach.
16.
DOCKS, WHARVES and PIERS
Does the Club have docks, wharves, or piers on the premises?
YES
NO
If Yes, please provide the following:
AGE:
CONSTRUCTION TYPE:COVERED?
YESNO
MAINTENANCE (describe):
HOW ARE THEY USED?
IS REPLACEMENT COST DETERMINED ANNUALLY?YESNO
What is the replacement cost?
This value should be included on the Statement of Values.
17. / EARTHQUAKE COVERAGE (Must be completed if this type of coverage is desired.)
Is the Club eligible for Emergency Flood Program Insurance?
Is the Club eligible for National Flood Insurance Program?
YES
YES
NO
NO
SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630
Golf & Country Club Application:
New Business Questionnaire
18.
POLLUTION LIABILITY COVERAGE (Multiple coverage options available.)
PESTICIDE / HERBICIDE APPLICATORS and POOL CHEMICALS COVERAGE?
YES
NO
If Yes, are your employees licensed to apply pesticides/herbicides?
YES
NO
Please provide:
NAMES:LICENSE NUMBERS:EXPIRATION:
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Are you requesting limited pollution liability coverage (including off-site cleanup)?
YES
NO
If Yes, the SIS Limited Pollution Liability Questionnaire must be completed and submitted.
For Above Ground Storage Tanks, please complete and submit the SIS Above Ground Tanks Questionnaire.
19.
CLUB PROFESSIONAL REPLACEMENT EXPENSE COVERAGE
Name(s) needed to activate coverage:
MANAGER
GOLF PRO
TENNIS PRO
20.
UMBRELLA LIABILITY
Please complete and submit the Umbrella application.
21.
WORKERS’ COMPENSATION
Please complete and submit the Workers’ Compensation application, experience modification worksheet, and
an updated 4 year loss history.
22.
COMMERCIAL AUTO
Please complete and submit the Commercial Auto application.
23.
DIRECTORS and OFFICERS LIABILITY
Do you want this coverage quoted?YESNO
If Yes, an SIS Club Program Directors & Officers application must be completed and submitted.
NOTE: If written through SIS, the Umbrella coverage can become excess of D&O coverage, if requested.
24.
FIDUCIARY LIABILITY
Do you want this coverage quoted?YESNO
If Yes, an SIS Fiduciary Liability questionnaire must be completed and submitted.
25.
EMPLOYEE BENEFITS LIABILITY
Which employee benefit programs are covered by the Club’s Employee Benefit Liability insurance?
SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630
7
Golf & Country Club Application:
New Business Questionnaire
8
Who administers the Club’s employee benefits programs and enrollment?
Have there been any claims in the past 5 years made under this insurance?
If Yes, please explain:
Do you have any knowledge of an occurrence that may lead to a claim under this coverage?
If Yes, please explain:
26.
YES
NO
YES
NO
YES
NO
YES
NO
GOLF TOURNAMENT / SPECIAL EVENT COVERAGE
TOURNAMENT / EVENT CANCELLATION COVERAGE:
Does the Club allow outings from outside parties that could cancel due to adverse weather?
If Yes, and the Club would like to insure the potential loss of income due
to cancellation or postponment, please provide:
EVENT DATES:
INSURED LIMIT REQUESTED:
HOLE IN ONE EVENT / TOURNAMENT COVERAGE:
Does the Club host events where coverage for “hole-in-one” contests is needed?
If Yes, and coverage is requested, please provide the following for each date:
NAME OF TOURNAMENT(S):
DATE OF EVENT(S):
NUMBER OF PARTICIPANTS (amateur/professional):
NUMBER OF HOLES:
YARDAGE:
PRIZE VALUES TO INSURE:
COMPLETED BY (please print or type): ______________________________________________ TITLE: _________________________
SIGNATURE (Insured): ___________________________________________________________ DATE: _________________________
In addition to this completed and signed questionnaire, we require the following:
• Completed applications signed by the broker on all lines of business that are being submitted. Include the Club’s FEIN number.
• A Statement of Values, including a complete COPE (construction, occupancy, protection, exposure) with number of levels, square
footage, and years of construction for all buildings to be covered. If the main building is older than 10 years, provide renovation dates
and specifics.
• Four-year hard copy of company loss runs, including current year, for each coverage line to be quoted.
• Most recent audited financial statements or income and expense statement.
• Auto coverage must include a copy of driver(s) MVR and zip codes for each vehicle.
• A schedule of the Club’s maintenance equipment with Replacement Cost Values.
Completed and signed questionnaires / applications must be provided for quote requests for any of the following:
Limited Pollution Liability/Environmental Pollution Legal Liabitliy; Above Ground Storage Tank Liability; Directors & Officers
Liability (not for profit / for profit available); and Fiduciary Liability.
PLEASE CONTACT YOUR SIS REPRESENTATIVE with any questions. Thank you for letting us serve you!
SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630
STATEMENT of VALUE
NAME of INSURED: ___________________________________________________________
REPLACEMENT COST:
ADDRESS: __________________________________________________________________
90% _____________________
___________________________________________________________________________
100% ____________________
CONTACT PERSON: _________________________________________________________________________________________
PHONE: __________________________________ EMAIL: __________________________________________________________
BUILDING
NUMBER
(1)
(2)
ADDRESS/
LOCATION
CONSTRUCTION
TYPE (1)
OCCUPANCY
SQUARE
FEET
FRAME, MASONRY, JOISTED MASONRY, NON-COMBUSTIBLE (STEEL)
SPRINKLERS, ALARM, and/or CENTRAL STATION
AGE
INSTALLED
PROTECTION (2)
BUILDING
VALUE
PERSONAL
PROPERTY
VALUE
TOTALS:
INSURED SIGNED: __________________________________________________
AGENT/BROKER: ______________________________________
TITLE: ____________________________________________________________
ADDRESS: ___________________________________________
DATE: ____________________________________________________________
CITY/STATE/ZIP: ______________________________________
SPORTS INSURANCE SPECIALISTS, LLC • 4115 Clubview Drive, Fort Wayne, IN 46804 • P: 260.969.0305 • Toll Free: 855.969.0305 • F: 260.459.1630