Martial Arts Insurance Application

Transcription

1 Martial Arts Insurance Application Risk-Can Underwriting Managers Mayfield Road Edmonton, AB T5P 4P4 Phone: (780) Fax: (780) Toll Free: SECTION 1: APPLICANT INFORMATION 1. Official / Legal Name of Organization: 2. Address: 3. City: Province: Postal Code: 4. Phone: Fax: 5. Website Address: 6. Will you require an additional named insured to be added to the policy? Yes No If Yes, please provide their information: SECTION 2: UNDERWRITING INFORMATION 1. Inception date of business: 2. Is your business: Sole Proprietorship Partnership Incorporated Company 3. Do you operate in countries other than Canada? Yes No 4. Name of association/federation affiliated with: 5. Are you a non-profit organization? Yes No If Yes, please give the name of the organization: 6. Do you require Directors & Officers Liability? (If so, there is an additional charge for this.) Yes No 7. Is the premises where you operate from: Owned by you Rented from someone Sub-leased by you 8. Activities and Gross Receipts (If new venture, please estimate): Operation Yes No Gross Revenue Split Students receipts Training receipts Clothing receipts Summer Camps Supplement receipts Selling of products Equipment Rental Food Concession Alcohol & Beverages Others (Please specify) 9. Is your facility licensed for all these activities that you conduct? Yes No If No, please explain: Martial Arts Insurance Application Page 1 of 8

2 10. To help assist us to better understand your organization, we require the following information: Copy Of Yes No If No, please explain: Letter of Patent (if incorporated) Last financial statements All insurance policies Participant Registration Forms Waivers / Release Forms being used Agreements Students contracts Medical Questionnaire Resumes & Certifications for each instructor Copy of information on your martial art Any available advertising materials / brochures Landlords information (if leased premises) 11. Do you have a filing system for these records (above mentioned) and how long do you maintain your records? 12. Do you use sub-contractors to deliver part of your service offering? Yes No If Yes, do you require a proof of insurance from contractors? Yes No 13. Do you provide services to other business as a sub-contractor? Yes No 14. Do you sell products at your location? Yes No If Yes : a) Do you sell lethal weapons? Yes No b) Do you manufacture or re-label any products as your own product? Yes No c) Do you sell instructional videos or CD s that you personally produce? Yes No 15. Limits Requested: $1,000,000 $2,000,000 $5,000,000 SECTION 3: (ACTIVITY) OPERATION INFORMATION PROCEDURS 1. Address of operation (if different then the applicant s address) Address: City: Province: Postal Code: Phone: Fax: 2. Which of the following traditional names most closely resemble the art(s) that you teach (Check all that apply)? Aikido Cardio Kickboxing Krav Maga Conventional Boxing Choi Kwang Do Kung Fu San Soo Jujitsu Goju-Ryu Muay Thai Kendo Gracie Jujitsu Savate Kung-Fu Jeet June Do Shito-Ryu Ninjitsu Judo Shotokan Tai Chi Karate Tae Kwon Do Woda-Ryu Kempo Other: Brazilian Jujitsu Kickboxing 3. Describe each of your operations in detail (one by one): Martial Arts Insurance Application Page 2 of 8

3 4. Do you have a fighting ring? Yes No 5. Describe the flooring of the dojo area: 6. Do you permit the following activities: a) Free Sparring? Yes No If Yes, is it: light contact full contact Are kicking motions to head permitted in sparring? Yes No b) Grappling? Yes No c) Conventional Boxing? Yes No If Yes, please explain: d) Kickboxing? Yes No If Yes, is it: light contact full contact e) Weapon Training? Yes No If Yes, do you use live or bladed weaponry? Yes No f) Do you teach no-holds-barred confrontation or submission fighting? Yes No g) Do you permit sleepovers on your premises? Yes No h) Sponsor or participate in tournaments/contests/competitions?* Yes No * Please note that tournaments/contests/competitions are covered only if amongst the students of the club. Martial Arts Insurance Application Page 3 of 8

4 7. Do you offer any activities other than martial arts? Yes No 8. Length of time in business at this location: years Total experience in this type of business: years Brief description if experience is related to other: 9. Total Number of Managers: Total Number of Instructors: Total Number of Volunteers: Total Number of Employees: 10. Total Number of Current Members: Provide a break-up of members/users of your facility by the following age category in your facility. Percentage of Females Males Total Youth: Participants Ages to 12 years of age: Participants Ages 13 to 19 years of age: Senior: Participants Ages 20 to 40 years of age: Participants Ages 40+ years of age: 11. If under 18, do you get the Consent Form and the Waiver signed by a Parent or Legal Guardian? Yes No 12. In your opinion, how many of the members/users are classified as: Novice Level (little or no experience): Intermediate Level (some experience): Senior Level: Advanced Level (certified level): Total Participants: 13. Activity time-line: Number of user days: 365 days a year: 260 days to 364 days a year: 208 days to 259 days a year: 156 days to 207 days a year: 155 days to less than a year: If other, please explain: Average time spent per visitor at the facility? Total number of visits (approximately per year, ie. if an individual comes twice per week for 52 weeks, the number is 104 visits): 14. What is your minimum instructor to participant ratio? 15. Please outline educational information given to group s prior to commencement of activity: Martial Arts Insurance Application Page 4 of 8

5 SECTION 4: STAFFING PROCEDURES 1. How is each Instructor certification, qualification and experience verified? Please describe: 2. Do you perform a background check on all employees? Yes No 3. Do you hire or employ anyone younger than 18 years old? Yes No If Yes, please give responsibilities assigned to these employees: 4. Do you provide training or review the procedures for equipment and safety with the staff on a regular (monthly) basis? Yes No 5. Are all instructors certified for First Aid training or CPR? Yes No Please submit the Supplementary Instructor Information Questionnaire for each instructor. SECTION 5: PARTICIPANTS SAFETY 1. Do you follow the standard safety measures as set by your governing body? Yes No 2. Are all safety rules posted? Yes No 3. Are the sparring rules typed on school letterhead, given to all students and signed and dated by the school s owner? Yes No (Please attach a copy.) 4. Do you have a client (participant) package of information for safety issues, medical information, waivers, rules, regulations and clothing checklist, in advance of the commencement of the activity? Yes No If Yes, please attach a sample. 5. Are there any coat hooks or sharp objects (shelf brackets, trophies, etc.) in the dojo area? Yes No 6. Is the chief instructor present at all classes? Yes No 7. Do you require all participants to wear the following protective gear: Head gear Mouthpieces Groin cup Chest protectors Boots Yes No 8. What is the proximity to closest medical facility? 9. What First Aid treatment is available at your premises? 10. Do you provide: Alcoholic beverages Supply food and meals, on trips or at any other time to the participants? If you do, please give details: 11. Do you have an incident and post incident reporting plan? Yes No Please explain: Martial Arts Insurance Application Page 5 of 8

6 12. Do you have instructors protocols? Yes No 13. Describe the precautions taken to avoid slips and falls at entrances in all weather conditions? 14. Are shower areas covered with non-slip floor covering materials? Yes No 15. Are the parking lots well-lit and patrolled? Yes No 16. Describe the participant management procedures for this activity: 17. Describe actions taken and decisions made to avoid specific hazards in the activity (ie. things you do or do not do): 18. Describe actions taken and decisions made to reduce the frequency of accidents in this activity (preventing incidents): 19. Describe actions taken and decisions made to reduce the severity of accidents in this activity (ie. reducing the impacts of an incident): SECTION 6: AUTOMOBILE EXPOSURE 1. Do you transport equipment and participants with your own or leased vehicle(s)? Yes No 2. Limits of Insurance carried: $ 3. Average lengths of road or vehicle travel: kilometers 4. Type of road used: Highway Rural City Routes Off-road 5. Do you have any owned or leased vehicle(s) inspected by a qualified mechanic? Yes No If Yes, is the inspection report logged into a permanent file? Yes No 6. Do you have a regular maintenance program in place to ensure standard vehicle safety? Yes No 7. Do participants use their own vehicle(s) as well? Yes No SECTION 7: INSURANCE & LOSS HISTORY INFORMATION 1. Do you currently carry any Commercial General Liability or Professional Liability insurance? Yes No If Yes, please provide details below. Current Carrier: Premium: $ Martial Arts Insurance Application Page 6 of 8

7 2. Has any insurer ever declined, cancelled or imposed special conditions for any coverage, for you or your facility in the past? Yes No 3. Have You or your facility ever been subject to disciplinary proceedings for professional misconduct by a professional society or any statutory registration board? Yes No 4. Are you aware of any circumstances which may result in a claim against you or your facility? Yes No IF YOU ANSWERED YES TO ANY QUESTION IN 3, 4 AND/OR 5 THEN YOU MUST PROVIDE FULL DETAILS ON A SEPARATE PAGE. 5. Loss History, please provide details below (attach additional page(s) if necessary): Year Insurer Premium Details of Loss(es) # of Loss(es) Total Amoun(s) Paid SECTION 8: OTHER INFORMATION 1. Please provide any other information you feel would assist in the evaluation of your application: SECTION 9: DECLARATION It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or to Risk- Can Underwriting Managers until accepted by Risk-Can Underwriting Managers, but that the information contained herein shall be the basis of the contract should a policy be issued. I declare that the statements made in this application are complete and true to the best of my knowledge. I understand that the Application Form will form part of the insurance policy. I acknowledge that if, at any time of claim, it is discovered that any question in this application is not answered truthfully, accurately and completely, it may result in the non-payment of any claim and/or my coverage will be made null and void. Your privacy is protected: The insurance coverage you are applying for is provided to you by Risk-Can Underwriting Managers and Risk-Can Underwriting Managers will collect, use and disclose the personal information, which you give, for the purpose of providing you with insurance services. Your information may be disclosed to others in the credit services, investigative and/or insurance fields as necessary to underwrite and administer this insurance and to pay any benefits. APPLICANT S NAME (PLEASE PRINT) SIGNATURE OF APPLICANT DATE (MM/DD/YYYY) Agent Name: Broker Name: Phone: Fax: BROKER CONTACT INFORMATION Address: City: Province: Postal Code: Martial Arts Insurance Application Page 7 of 8

8 SUPPLEMENTARY INSTRUCTOR INFORMATION QUESTIONNAIRE (Please complete one form for each guide/instructor.) SECTION 1: GENERAL INFORMATION 1. Your position is: Head Instructor Assistant Instructor Apprentice Instructor 2. Your name and address: 3. Telephone Number: Fax Number: SECTION 2: EXPERIENCE AND CERTIFICATION 1. Years operating as Head / Assistant / Apprentice Instructor: 2. Number of trips operating as Head / Assistant / Apprentice Instructor: 3. Experience as an Instructor: 4. Is this a full time occupation? Yes No 5. Please indicate number of hours worked per year: 6. Please indicate your level of First Aid training: 7. What are your certifications that qualify you, to be an Instructor? 8. Does your certifying body require you to continue your education to maintain your certification? Yes No If Yes, please describe: If No, please describe if you pursue continuing education on your own: SECTION 3: CLAIM INFORMATION 1. Have you ever been involved in an accident in the past for this type of activity? Yes No If Yes, please give details: Please provide a copy of information on the certification program. Martial Arts Insurance Application Page 8 of 8