Martial Art Program Form - BrokerForce Insurance

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Martial Arts Program Quote Request Form

Please complete the form below, and our Martial Arts program director will contact you shortly.

"*" indicates required fields

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*

Month

Day

Year

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)

Aikido

Boxing (no sparring)

Boxing

Brazilian Jiu Jitsu (incl. no Gi)

Capoeira

Grappling/Wrestling

Laido/Jiu Jitsu

Judo

Karate

Kickboxing (no sparring)

Kickboxing

Kendo

Krav Maga (no sparring)

Krav Maga

Kung Fu

MMA

Muay Thai

Tai Chi

Yeakwondo

Other

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

Δ

Phone

Address

608 - 200 Consumers Road
Toronto ON
M2J 4R4

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