Ice Rink Application For General Liability Insurance

Transcription

1 Ice Rink Application For General Liability Insurance General Information Proposed Effective Date Rink name (DBA) Corporate name: Mailing address: (Street) (City) (State) (Zip) Location address (if different): (Street) (City) (State) (Zip) Rink phone #: ( ) Home phone #: ( ) Office phone #: ( ) Fax #: ( ) Website: Applicant is: Corporation Partnership LLC LLP Not For Profit Other Do you own or lease the premises? Own Lease If leased, what are the other occupancies/tenants in the building, if any? List skating associations of which you are a member (e.g. ISI/STAR/NEISMA/MIRMA, etc): Is this a new operation? Yes 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? Yes No IF SO, PLEASE PROVIDE NAME(S): Do you conduct any other business under the named insured on this application? Yes No IF SO, PLEASE DESCRIBE: IceRinkApp 1

2 Annual Gross Receipts Breakdown General Admissions Receipts ($) (If n/a, please so indicate.) Open Public Skate Skate Rental Ticket Sales to Spectators Broomball Rink Sponsored Lessons Figure Skating Learn to Skate Hockey Other: Camps Clinics Rentals League Hockey Youth Hockey Open Hockey Waiver/disclaimer used on ticket? (If yes provide copy) Are Waivers signed by participants? Are participants members of: USFSA ISI Do you collect certificates of insurance from instructors? Are participants members of: USFSA ISI Do you collect certificates of insurance from instructors? Are participants members of: USAH ISI Do you collect certificates of insurance from instructors? Are participants members of: USAH ISI USFSA Do you collect certificates of insurance from instructors/operators? Are participants members of: USAH Are participants members of: USAH Are participants members of: USAH IceRinkApp 2

3 Figure Clubs/Events Are participants members of: USFSA ISI Other Tournaments/Shows/ Competitions In-line Hockey Dry Floor Other Revenues Pro Shop Skate Sharpening Snack Bar Restaurant Liquor sales Long term leases (tenants) Vending Advertising Other please indicate $ rent Leased space Sq Ft. Are participants members of: USAH ISI USFSA Other Are participants members of: USAH Do you collect certificate(s) of insurance? PLEASE ATTACH TO THIS APPLICATION AND INDICATE ATTACHEMENTS: 1.) COPY(IES) OF INSTRUCTORS CERTIFCATES OF INSURANCE 2.) COPY(IES) OF CONTRACT RENTALS CERTIFCATES OF INSURANCE 3.) COPY(IES) OF WAIVER(S) USED 4.) COPY(IES) OF PROGRAM REGISTRATIONS 5.) COPY(IES) OF ICE RENTAL AGREEMENT 6.) COPY(IES) OF TENANT S LEASE 7.) COPY OF YOUR LEASE IceRinkApp 3

4 Physical Plant and Maintenance Information Number of stories: Total square footage: # of Skating surfaces: Length x Width = SQ FT Height of boards: Height of glass at sides: Height of at ends: Do you have netting? Describe: (full/ends/other) 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: HVAC: Do you have any spectator seating? Yes No Type of Construction: Age: Do you have the following: (If yes, please attach copies for underwriting) Rink rules posted? Skaters Code of Conduct posted? Written emergency plan(s)? Safety inspection checklist? Skate maintenance log? Ice resurfacing log? Video Surveillance? Describe areas of coverage Please describe regular maintenance on rink: Do you document this maintenance in writing? If yes, describe: Have you installed a fire alarm? Have you installed a burglar alarm/motion detector? Do you have outside security? If so, how many? Are they armed? Do you have emergency exits? If so, how many? Are they locked? Are there panic bars on exit doors? Do you have safety and emergency lights? How often are they tested/serviced? Who maintains your parking lot and sidewalks? Year last resurfaced: Do you have certified first aid personnel? Yes No CPR First Aid Number per session: Do you have an AED? Number of personnel trained to use: Do you have a deep fryer or a grill? If yes, is it approved by the Fire Marshall? How often is the system cleaned? IceRinkApp 4

5 Maximum occupancy rate: per fire code Describe the ventilation system at your rink: What is the fuel source for your ice resurfacing equipment? Rink Use Information Maximum # of skaters per floor guard: Maximum capacity of rink: Do you have special programs? If yes, please describe: Do you have banquets or dances? If yes, please describe: Do have skating competitions? If yes, are there sponsoring or sanctioning organizations? If yes, please provide names: Do you have any of the following or conduct the following on your premises? Travel Hockey Other events off your premises If yes, describe: Speed Skating Broomball In-Line Skating Exercise/Dance Equipment Sales Equipment Rental Type Equipment Repair Day Care Laser Tag Bus, car or transportation service Sale of alcohol Fitness Center Soccer or other sports Dry floor events If so, describe: Other Activities If other, please explain: Staffing Information Total number of staff: Full time (40 hours): Part time: Minimum age of skate guards: Years Experience: Owner s name: Years Experience: Manager s name: Years Experience: IceRinkApp 5

6 Has your staff taken any continuing education courses? Name of course(s): Sponsoring Organization(s)? Date(s) taken: Are instructors/coaches: Employees Independent Contractors (If so, attach contract) Do you have volunteers working for you? IF SO, PLEASE DESCRIBE: Please complete for the last five years: Expiring Insurance Carrier Information YEAR COMPANY & POLICY NUMBER (LIABILITY) LIABILITY LIMITS DEDUCTIBLE PREMIUM Has insurance ever been refused or canceled? If yes, please describe on a separate sheet of paper, or provide copy of cancellation notice. Claims and Incident Report Data Average number of incidents and/or claims for the last three (3) years: per week per month per year List any CLAIMS/LOSS HISTORY for the last five (5) years in which the loss paid or reserved is in excess of $25,000. Use separate sheet if necessary and include circumstances concerning alleged injury, amount paid, facts about the case PLEASE ATTACH CURRENTLY VALUED INSURANCE COMPANY LOSS RUNS. On a separate sheet of paper give a full description of EACH loss over $5,000 (circumstances concerning alleged injury, amount paid, facts about the case). IceRinkApp 6

7 Coverages Requested Proposed effective date: LIMIT OF LIABILITY OPTIONS: $1,000,000/2,000,000 Excess Liability $ limit $1,000,000/ Hired & Non-owned Auto Liability Employee Benefits Liquor Liability Other Additional Insureds/Certificate Holders Do you need any additional insureds on your policy? If yes, list below and attach a copy of contract requiring additional insured status. IceRinkApp 7