Gymnastics Application Gymnastics Insurance Application Step 1 of 3 33% Policyholder InformationFacility NameEmail PhoneContactFirst and Last NameTitleBusiness Start YearType of Operation LLC Individual/Sole Proprietor Partnership Joint Venture Corporation Other Description of OperationsWebsite Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is Mailing Address the same as the Physical Address? Yes No Physical Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Enter facility address if different from mailing addressDo you have multiple locations? Yes No Physical Address 2 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address 3 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Requested Start Date MM slash DD slash YYYY Are participants required to sign a Waiver & Release of Liability for all activities? Yes No Does facility have a Code of Conduct? Yes No The facility's code of conduct should outline the facility's standards of the behavior and expectations for staff and members.Has applicant ever filed for bankruptcy? Yes No Is there prior insurance coverage? Yes No If yes, who is your current insurer?Has applicant ever been non-renewed? Yes No If yes, please describe:Has applicant had a liability or accident claim in the last 5 years over $25,000? Yes No If yes, please describe:Annual RevenueProvide Estimated annual number of participants for each sport/activity and age group for which you like to provide coverage.Sport/Activity12 & Under13 -1516 - 1819 +Coaches Add RemoveCoverage will only be quoted and provided for the sport/activity and age groups you specifically indicate below. Click the "+" to add additional fields for cheer, dance, tumbling, etc. Do you host camps, clinics or special events? Yes No Camps/Clinics/Special EventsSport/ActivityNumber of Camp/Clinic Days12 & Under13 -1516 -1819 + Add RemoveList out any hosted camps, clinics or special events hosted at facility with number of participants per age rangeAre any camps/clinics overnight? Yes No If yes, how many nights?Do you offer or host special events? Yes No If yes, how many special events per year?If yes, please describe special events: General Liability CoveragesEach Occurrence Limit $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 If higher than $1,000,000 occurrence is selected, is it a contract requirement? Yes No If yes, please send contract requirement or agreement to us when you finish this application.Products and Completed Operations Limit $1,000,000 $2,0000,000 $3,000,000 General Aggregate Limit $3,000,000 $4,000,000 $5,0000,000 Damage to Premises Rented Limit $300,000 $500,000 $1,000,000 Personal Advertising Injury Limit $1,000,000 Add Medical Payments Limit $5,000 $10,000 Decline This Coverage Add Sexual Abuse Liability Limit $25,000/$100,000 $50,000/$100,000 $100,000/$300,000 $500,000/$500,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000 Decline This Coverage Per Occurrence / AggregateAdd $1,000,000 Hired or Non-Owned Auto Liability? Yes No Add Professional Liability Limit $1,000,000/$1,000,000 $1,000,000/$3,000,000 Decline This Coverage Add $1,000,000 Employee Benefits Yes No If yes, how many employees:General Underwriting QuestionsIf applicable, will the standard safety gear for the sports be required? Yes No Are any of the applicant's players compensated/paid to participate? Yes No Is the applicant's organization sanctioned by a school? Yes No Do any activities take place on residential property? Yes No Does the organization clearly define who Adult Participants are? Yes No Applicant has policies in place for cardiac arrest and heat stroke? Yes No Do any activities take place at a pool that the applicant owns, operates, leases or manages? Yes No Does applicant own, operate, or manage a facility? Yes No If yes, do you offer unstaffed access or open 24 hours? Yes No Does facility maintain camera recordings of premises, both inside and outside? Yes No Does applicant offer child watch or day care services? Yes No Do you offer orientation for members? Yes No Are risk management policies distributed to staff & readily accessible for members? Yes No Are education and trainings in place for staff members to maintain appropriate certifications? Yes No Is there daily cleaning of the facility & equipment to reduce the spread of communicable disease? Yes No Equipment maintenance policy in place that includes scheduled inspections with maintenance logs? Yes No Is equipment installed by either a manufacturer or a third-party vendor? Yes No Is there a signage policy for locker rooms, saunas & other high-risk areas? Yes No Do you have video coverage of both interior and exterior of the premises? Yes No If yes, are recordings saved for at least 90 days? Yes No Do you have an above ground trampoline, other than a tumble track, that is greater than 46” in diameter? If yes, attach photos of trampoline(s). Yes No Do you inspect or provide guidance around inspection of bleachers , goal safety, field maintenance, including clean-up of equipment and debris? Yes No Applicant has and enforces written standards regarding Sexual Abuse and Molestation prevention and reporting? Yes No Applicant has a formal policy for and runs background checks, which includes an appeals policy for disqualified participants? Yes No Has the applicant ever had an incident which resulted in allegation of sexual abuse? Yes No Is there a formal training program in place for abuse and anti-bullying? Yes No Does the applicant have policies and procedures that limit one-on-one interactions (both in person and social media/text/email communications) between adult participants (coaches/trainers) and athletes/participants (particularly those that are minors)? Yes No If yes, is it implemented? Yes No Do you transport participants to or from games, camps, clinics or events? Yes No If yes, please explain:Does Applicant provide online training/coaching/instruction? Yes No Applicant distributes a written concussion awareness policy (i.e., CDC's HEADS UP) to coaches, parents, and players? Yes No If a possible concussion has occurred. Applicant immediately removes the athlete from play or practice? Yes No Applicant’s concussion policy requires a medical doctor's release prior to the child returning to play after a suspected concussion? Yes No Is applicant a Non-Profit? Yes No Do you work with professional athletes? Yes No Do you offer cryotherapy? Yes No Cryotherapy, sometimes known as cold therapy, is the local or general use of low temperatures in medical therapyDo you offer soft play? Yes No Soft play refers to a specifically-designed play area where almost all surfaces and equipment are covered in thick paddingAccident and Health Coverages (required with youth participants)Accident Medical Expense Limit $25,000 $50,000 $100,000 Deductible $100 $250 $500 $1,000 Include Dental Services? Yes No Additional Exposures (if applicable)Number of Swimming PoolsNumber of Diving BoardsNumber of saunasNumber of Batting CagesNumber of Zip Lines under 6ft.Number of Trapezes under 6ft.Number of Traverse/Climbing Wall up to 10 ft.Number of climbing ropes under 6 ft.Number of Aerial Silks under 6 ft.Number of Aerial Silks over 6 ft.Number of Aerial SilksNumber of Tanning BedsNumber of Booster ClubsNumber of Birthday Parties per yearNumber of JacuzzisNumber of Inflatables Additional InsuredPlease list the name and address(es) of any additional insureds needed for a lease, landlord, or venueName of Additional Insured:Address of Additional Insured: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Additional Insured:Address of Additional Insured: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Consent I certify that the above information is true and coverage is not applicable until quoted and accepted by the carrier. This is only an application for a quote.Name of persona completing application First Last
