• Club Insurance Questionnaire

  • Applicant is:
  • How did you hear about us?

  • GENERAL INFORMATION

  • 5. Is the club restricted to club members and their guests?
  • 7. Is indoor smoking allowed?
  • 8. Check all that apply to your operation:
  • 10. Any international operations? (If yes, describe by attachment.)
  • 11. Do you engage in fundraising? (If yes, describe below in section for events.)
  • 12. Any medical services or medical advice of any kind provided to members or to the public?
  • 13. Are any kinds of personal care or medical care services provided in any capacity?

  • FACILITY RENTAL

    (Complete this section if your organization rents your premises to others (receptions, parties, etc.))

  • 3. Are employees always on-site during facility rental?
  • 4. Is alcohol served or allowed on the premises during facility rental?
  • 5. Are renters required to sign a written rental contract? (If yes, please provide a copy of the rental contract).

  • CLUBHOUSE

  • 1. Tavern or restaurant occupancy?
  • 2. Describe the extent of cooking exposures inside of buildings with Restaurant or Tavern occupancy:
    Rows
  • 3. Is alcohol served or allowed on the premises?
  • Note: If Liquor Liability coverage is desired, please contact Kevin Morency for a quote. (Liquor Liability will only be available if we provide the General Liability for your club operation.)

  • EVENT INFORMATION

  • 1. Submit a list of scheduled club or organization meetings, gatherings, planned events, parades, and other activities that take place during the year, for which insurance coverage issued is to apply. This includes events or activities that are open to the public.
    Rows

  • Note: Events which are not restricted to club members and their guests, attracting more than 200 attendees, require the completion of a West Bend Special Events Questionnaire.

  • 2. Do you rent out the premises to non-members?
  • 2a. If yes, do you require proof of insurance and are you named as additional insured on their policy?
  • 3. Are you a professional or trade association?
  • 4. Are you a Neighborhood Association?

  • PROPERTY INSURANCE

  • 1. Do you need Building and/or Content Coverage?
  • 1a. If yes, please complete chart below or provide a separate property schedule with the following information:
    Rows
  • 2. Do you need Equipment Coverage?
  • 2a. If yes, total value to insure for?
  • 2b. If yes, please complete equipment schedule below or provide a separate equipment schedule with the following information:
    Rows

  • COMMERCIAL AUTOMOBILE INSURANCE

  • 1. Does the business title any automobiles or other operating vehicles in the business name?
  • 2. Is insurance coverage needed for owned automobiles?
  • 2a. (If yes, complete chart below or provide a separate vehicle/fleet schedule with following info.)
    Rows
  • 2b. If yes, limits desired:
    Rows
  • 3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?
  • 3b. Do you verify they have liability coverage?

  • COMMERCIAL CRIME

  • 1. Do you desire coverage for Crime (Employee Dishonesty, Money, Forgery)?

  • COMMERCIAL UMBRELLA

  • 1. Do you need a Commercial Umbrella?

  • DIRECTORS AND OFFICERS & WORKERS' COMPENSATION INSURANCE

  • 1. Do you need Directors and Officers Liability Coverage? (If yes, please contact Kevin Morency.)
  • 2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)
  • Privacy Policy and Terms & Conditions*

  • SIGNATURE

  • The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.

  • Questions? 877-244-9090
    kmorency@morencyinsurance.com 

    Kevin Morency, Licensed Producer
    Morency & Associates Inc.
    141 New Shackle Island Rd, Hendersonville, TN 37075
    Fax: 615-452-6580

    https://clubassociationinsurance.com/

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