Martial Art Program Form - BrokerForce Insurance

Contact Name*

First Name

Academy/Club Legal Name

Position

Business Phone*

Cell Number*

Email*

Club Mailing Address*

Address City Province Postal Code

Provide more info

Website

Is your academy affiliated with any provincial or national organization?*

Yes
No

Please list*

How many years have you been in business*

Are you a new venture?

Yes
No

Current policy expiry/requested new policy effective date*

Liability limit required*

Is Sport Accident coverage required?*

Yes
No

Is Legal Assist coverage required?*

Yes
No

Has the club ever been cancelled or non-renewed by an insurance company?*

Yes
No

Please explain*

Any liability, injury, or property losses/claims in the past five years?*

Yes
No

Please list*

Martial Arts Disciplines practiced: (Select all that apply)

If selected 'Other' please specify?

Any other activities? (eg: Fitness, Yoga, Zumba, etc.)*

Yes
No

Please list*

Annual Gross Receipts*

How many locations do you operate?*

Total number of active club participants? (Including all classes, day camps, and after-school programs)*

Is a liability waiver/release for signed by each participant?*

Yes
No

Do any students participate in sparring? (ie: striking)*

Yes
No

Is full protective equipment worn? (head, mouth, groin, hand, leg)*

Yes
No

Are any weapons used?*

Yes
No

Please describe (type, used for kata, technique, or sparring?)*

Total number of instructors*

Are all coaches/instructors certified?*

Yes
No

Any off premises activities?*

Yes
No

Please describe*

Any activities/events outside of Canada?*

Yes
No

Please describe*

Do you offer food or beverage services?*

Yes
No

Snacks/Drink bar*

Yes
No

Vending Machines*

Yes
No

Please describe food service operations (items offered, staffed or unsupervised, approx annual sales)*

Any children's after school programs?*

Yes
No

How many NON-MEMBER participants are expected?*

Details*

Any children's birthday parties?*

Yes
No

Approximately how many parties per year?*

Any day camps? (eg: P.A. days, March Break, Summer etc.)*

Yes
No

How many NON-MEMBER participants are expected?*

Details*

Tournament

Do you ATTEND any tournaments?*

Yes
No

List how many and the number of your members attending each*

Do you HOST any tournaments?*

Yes
No

List how many and the number of participants and spectators attending each*

Is participant liability covered by a sanctioning body?*

Yes
No, coverage is required

Seminars

Do you ATTEND any seminars?*

Yes
No

List how many and the number of your members attending each*

Do you HOST any seminars?*

Yes
No

List how many, whether on or off site, and the number of NON-MEMBER participants attending each*

Events

Do you ATTEND any events? (eg: Social, Fundraising, Terry Fox run, etc.)*

Yes
No

List and describe each event and specify the number of your members attending each*

Do any events involve alcohol?*

Yes
No

Describe*

Location #1 - Property Information

Club Location Address 1*

Street Address City Province Postal Code

Years at this location 1*

Do you own or lease the building? 1*

Owned
Leased

Number of Employees 1*

Area you occupy - Square Footage (sq ft) 1*

Combines value of: building (if owned), Contests, Unit Improvements, and Equipment 1*

Building age/year built 1*

Number of stories 1*

Fire Protection 1*

Additional details 1

Additional Locations

Add location 2

Location #2 - Property Information

Club Location Address 2*

Street Address City Province Postal Code

Years at this location 2*

Do you own or lease the building? 2*

Owned
Leased

Number of Employees 2*

Area you occupy - Square Footage (sq ft) 2*

Combines value of: building (if owned), Contests, Unit Improvements, and Equipment 2*

Building age/year built 2*

Number of stories 2*

Fire Protection 2*

Additional details 2

Add location 3

Location #3 - Property Information

Club Location Address 3*

Street Address City Province Postal Code

Years at this location 3*

Do you own or lease the building? 3*

Owned
Leased

Number of Employees 3*

Area you occupy - Square Footage (sq ft) 3*

Combines value of: building (if owned), Contests, Unit Improvements, and Equipment 3*

Building age/year built 3*

Number of stories 3*

Fire Protection 3*

Additional details 3

Add location 4

Location #4 - Property Information

Club Location Address 4*

Street Address City Province Postal Code

Years at this location 4*

Do you own or lease the building? 4*

Owned
Leased

Number of Employees 4*

Area you occupy - Square Footage (sq ft) 4*

Combines value of: building (if owned), Contests, Unit Improvements, and Equipment 4*

Building age/year built 4*

Number of stories 4*

Fire Protection 4*

Additional details 4