Fax, Mail or E-Mail Application to:	AMERIKIDS GYMNASTICS
Foy Insurance Group, PO Box 1030	CLUBS & PROGRAMS
Exeter, NH 03833	E-mail jim.foy@foyinsurance.com
Phone 603-772-4781 Fax 603-772-3246	Or mike.foy@foyinsurance.com
Insured/Contact person:		Date:	
Legal Business Name:		
Mailing Address:	PO Box or Street Address:	City:	State:	Zip:	
Location Address:	Street Address:	City:	State:	Zip:	
Gym Phone:		Web site:	E-mail:		
Cell Phone:		Best time to call:		Fax #		
NEW:	RENEWAL:	CURRENT INS. COMPANY:	EXP DATE :
Month:	Day:	CURRENT PREMIUM:
$	
Total # of Gym participants:	Corp	, Sole Owner	,	Partnership		, Other		

My Club Has The Following Activities On The Club Premises: Answer YES or NO 
Activity	Yes	No	If yes, describe		
Dance			Type of dance	Number of dance students =		
Cheerleading			Pyramid height over 2 1/2 high?		
Martial Arts			Type:		
Aerobics/ Exercise/ Yoga					
Birthday Parties			# per year =		
Kids Night Out			# per year =		
Sleep overs			# per year =		
Climbing Wall or Zip line			wall height =		
Tumble Bus					
Swimming Pool					
Tanning Beds					
Entertainment Inflatable			Number & Description:		
Soft Play Area					
Circus Skills / Parkour					
Licensed Day Care					
Day Camps			Total # of camp days per year
Number of daily campers NOT enrolled as regular students =	per day		
Open Gym / tryouts			Total # of open gym days per year
Number of daily open gym attendees NOT enrolled as regular students =	per day	
Vehicle Registered to gym?			If so send copy of coverage part		
Do you host meets?			If so how many meets?	, Length of meets
Are all Amerikids registered?	Yes	No. Are meets USAG?	AAU?	
Any teaching off premises?			How often?	How many kids?
Are all Amerikids registered?		
Café, snacks, vending machines			Receipts =		
Booster Club			If yes are they a separate entity?	Yes	No
Describe type of fundraising of boosters:
Do you want to include them under your insurance?	Yes	No		
Pro Shop			Receipts =		
Any activities not listed above?					

Gym Participants		Gross Gym Receipts:		
Total # of recreational participants:				
				
Total # of competitive participants:		Do you wish to finance your premium? Yes	No	
Total # of dance participants:		NOTES:		
Total # of martial arts participants:				
TOTAL
(Including everything: gym, cheer, dance, etc.)				

List any persons, landlords, or organizations requiring you to list them as an “additional insured”

Name:

Address:

City, State, Zip

Please check method of reporting to Amerikids:	Annual	Monthly
What is the total number of students you have registered in the past 12 months?	
Number of years running a gym:	
Any losses in the past 3 years: 	 Yes (if yes please explain in detail in the remarks section) 	 No

Do you own the building?	Yes	No	Building Square Footage:	
If yes, in what name do you own the building?	
Do you sublease space to others?	
If so, to whom	 And for what purpose?	
AmeriKids Gymnastics Policy Limits:
Sports Accident	Liability Insurance
Sports Accident	$50,000	Liability Aggregate	$3,000,000	Additional Liability	
		Per Gym		Limits Available to	
Deductible	$250	Occurrence	$1,000,000	$5 million	
A D & D aggregate	$25,000	Fire Legal	$300,000	Check here for quote	
A D & D Each occurrence	$5000	Products	$1,000,000		

* Remarks:
Note: Any premium bearing policy endorsements will be invoiced separately and paid in full.
The submission of this application form does not guarantee coverage. Coverage begins with a complete enrollment form, full payment received and written approval issued.
Any person who knowingly presents a false claim for payment or a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Please forward a copy of your waiver and release form along with this application and sign below to request an Amerikids quote which may not include all requested coverages.
Signature:	Print	
Date:
Ed date 022311

TOTAL NUMBER OF STUDENTS REGISTERED TO YOUR GYM
EACH MONTH FOR THE LAST 12 MONTHS:

January:	
February:	
March:	
April:	
May:	
June:	
July:	
August:	
September: October:  November: December:

Do you want to include Sexual Abuse and Molestation with limits of $25,000 per occurrence / $100,000 aggregate (Higher limits available on request)
If coverage is requested, you must comply with the following requirements or coverage WILL NOT be afforded. Name of Gym:	
Address of Gym:
SML Coverage
Answer the following questions if the organization has and enforces written standards regarding Sexual Abuse and Molestation:
1.	Does the employment application for your paid staff and volunteers include questions about whether the individual has ever been convicted for any crime, including sex- related or child-abuse related offenses? YES/NO
2.	Does your state permit you to do criminal background investigations on prospective employees and/or volunteers? YES/NO
3.	If yes, do you routinely request and receive such background investigations? YES/NO/N/A
4.	How do you verify employment and/or volunteer related references? In Person By Telephone Do Not Verify
5.	Do you discuss child/sexual abuse including how to recognize the signs, and what to do if a staff personnel/child and/or volunteer reports someone molested him/her at your staff orientation? YES/NO
6.	Do you document it? YES/NO/N/A
7.	Do you have a plan of supervision that monitors staff including volunteers in day-to-day relationship with the children? YES/NO
8.	Do you have a crisis management plan for dealing with staff personnel, including volunteers, victim, parents, authorities and media if you have an incident of abuse? YES/NO
Insured Signature: Date:

If you would like a quote for Building, Contents, or Loss of Income please complete this page:  DATE:	
NAME that the property is owned under:	
ADDRESS:
PROPERTY
(If you own the building)
BUILDING LIMIT REPLACEMENT COST:	$
CONTENTS LIMIT REPLACEMENT COST:	$	OR ACV	
(Do you want us to quote for you?)
LOSS OF INCOME LIMIT:	$
(Do you want us to quote for you?)
DEDUCTIBLE: $1,000 OR OTHER	$
CONSTRUCTION TYPE: FRAME ___ OR MASONRY ____ YR OF CONSTRUCTION: _____ # STORIES: ____
WITHIN 1,000 OF A FIRE HYDRANT? ____
WITHIN 3 MILES OF A FIRE STATION? ____
IS THE BUILIDNG SPRINKLERED? ____
ANY ALARM SYSTEM? YES OR NO CENTRAL STATION OR LOCAL?
IF BUILT PRIOR TO 1985 BUILDING IMPROVEMENTS:
WIRING YR: ROOFING YR: PLUMBING YR:	HEATING YR:
TOTAL SQUARE FOOTAGE:	AREA OCCUPIED	
OTHER OCCUPANTS:
EXPOSURES WITHIN 50’? ADDITIONAL INTERESTS:
MORTGAGEE: ADDRESS:
LOSS PAYEE: ADDRESS:

AmeriKiDS Gymnastics Club Membership
($25 annual membership fee)
Please type or print clearly
Club Name:
Gym Address:	
Mailing Address:	
City: 	 State:	 Zip
Girls Program: 	Boys Program:	
Contact Name:
Phone: (	)	 Fax: (	)	 Alternate Phone:	
Required Email Address:	
(Most correspondence will be through email since it is the fastest way to communicate.)
Website Address:
Have you or any of your staff been:
Convicted of a felony?	
Convicted of sexual misconduct? 	
Denied membership in any other gymnastics organization?

Club owner or authorized agent’s printed name			
			
Club owner or authorized agent’s signature	Date
Your club membership allows for registration of athletes, sanctioning competitions and participation in AmeriKiDS sanctioned/member events and other specified benefits as they develop. Mail form and club membership fee of $25 payable to AmeriKiDS Gymnastics.