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For U.S. clients only. At this time we do not offer coverage in New York.

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We have made this intake form as simple as possible. In order for us to give you an accurate quote, You must fill out every single field, even if it does not apply to your situation -- just enter "NA" or "not applicable".

contact information

Contact Name:   Contact E-mail:   Contact Phone:   Contact Fax:  

club information

If you are a new business: please provide projected figures rather than past figures. Named Insured:   Location Address:   Mailing Address:   Effective Date:   Hours of Operation:   Current Ins. Carrier:   Club Square Footage:   Bldg. Square Footage:   Number of Members:   Est. Annual Gross:   Defibrillator on Premises  -  yes:   no:Digital Camera System  -  yes:   no: Years in Business:   24-hour Key Club  -  yes:   no: Claims in Past 3 Years:    

Explain Claims (enter NA if not applicable):

liability information

# Tanning Booths/Beds:   # of Saunas:   # of Jacuzzis:   # of Steam Rooms:   # of Volleyball Courts:   # of Basketball Courts:   # Racquetball Courts:   # of Tennis Courts:   # of Pools:   Pool Depth:   Pool Type   -   N/A:     Lap:     Therapy:     Olympic: # of Diving Boards:   Diving Board Height:  
Daycare or Babysitting  -  yes:   no:Outdoor Playground  -  yes:   no:

Daycare Activities Provided (enter NA if not applicable):

Restaurant or Cookingyes:   no:Annual Receipts:   Liquor Salesyes:   no:Annual Receipts:  
Massage TherapyIndependent:Employee:Not Provided: Martial ArtsIndependent:Employee:Not Provided: Physical TherapyIndependent:Employee:Not Provided: Day SpaSubcontracted:Owned:Not Provided:
Company-owned Vehicles  -  yes:   no:Insured Seprtly.  -  yes:   no:   n/a: Off-premises Activities with Transportation for Members   -   yes:   no: Other Activities (enter NA if not applicable): (i.e. running track, climbing wall,
rollerblading, mountain biking, school programs, kids' activities, 10K runs, etc.)

property information

Year Built:   # of Stories:   Miles to Nearest Coast:   Basement   -   yes:   no: If building is more than 20 years old, when was the last update: Plumbing Update:   Electrical Update:   Wall Construction    Concrete:Brick/Cinderblock:Steel Frame:  Wood Frame:Metal:  Roof Construction    Concrete:Brick/Cinderblock:Steel Frame:  Wood Frame:Metal: 
Occupancy to LeftRetail:Restaurant:Parking: Landscape:  Other:Explain Other:   Occupancy to RightRetail:Restaurant:Parking: Landscape:  Other:Explain Other:   Occupancy BehindRetail:Restaurant:Parking: Landscape:  Other:Explain Other:   Club is Located InStrip Mall:Freestanding:Office Complex: Other:Explain Other:  
Business Space is   -   Owned:   Leased:Alarm System   -   yes:   no: Space Leased to Others   -   yes:   no:Sprinkler System   -   yes:   no:

If space leased to others, specify (enter NA if not applicable):

Building Value (if required to insure):     Business Personal Property* (contents) Value:     Loss of Income* / Extra Expense Limit:    

*Business Personal Property Value to include equipment, tenants' improvements, furniture &
fixtures and inventory. *Loss of Income Limit to equal a minimum of three months’ gross receipts.

       


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