Monument Sports, a DOXA company
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USIndoor / Monument Sport Facility Program Application

Step 1 of 9 – I. General Information

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I. General Information

3. Do you own or Lease your Facility?
4. If owned, do you have a separate company that owns the building?(Required)
5. Does it have a separate Liability policy?

6. Location Address

7. Mailing Address

Mailing Address
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11. Does the insured conduct any other operations or own any other buildings under this name?
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20. Is your facility a current member of USIndoor?
For more information, visit USIndoor.

II. Coverage Information

1. Have you had any Liability Losses or Claims in the previous 5 years?
3. Coverage requested
Workers’ Compensation — Payroll Details

Provide annual payroll figures split between clerical and all other staff.

Clerical and office staff only
Please enter a number greater than or equal to 0.
All non-clerical payroll

III. Revenue and Activity Information

Revenue information is not required if a detailed Profit & Loss / Income Statement is provided.
1. Detailed Profit and Loss / Income Statement provided?
2. Revenue Information
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3. Please select all sports/activities that apply and provide the annual number of participants
Baseball
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
Basketball
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Batting Cages
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Boxing
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Dodgeball
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Field Hockey
Please enter a number greater than or equal to 0.
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Fitness/Health Club
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Football – Flag
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Football – Tackle
Please enter a number greater than or equal to 0.
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Floor Hockey
Please enter a number greater than or equal to 0.
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Golf
Please enter a number greater than or equal to 0.
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Gymnastics
Please enter a number greater than or equal to 0.
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Ice Hockey
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
Lacrosse
Please enter a number greater than or equal to 0.
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Laser Tag
Please enter a number greater than or equal to 0.
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Martial Arts
Please enter a number greater than or equal to 0.
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Inline Hockey
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
Soccer
Please enter a number greater than or equal to 0.
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Softball
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
Speed & Conditioning
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
Tennis
Please enter a number greater than or equal to 0.
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Ultimate Frisbee
Please enter a number greater than or equal to 0.
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Volleyball
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Wrestling
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Other 1
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Other 2
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Activities not covered without prior approval:
Bungee jumping, boxing, tackle football, concerts, comedy shows, licensed day-care operations, swimming pools/water attractions, skate parks, BMX operations, ice rink operations, tanning bed operations, amusement devices, go-karts or other motorized racing, carnivals/circuses/fairs, paint ball/reball, mixed martial arts, rock climbing walls, children’s play structures, inflatable games and bubble soccer.

IV. Building & Premises Information

1. What types of playing surfaces do you have?
2. Do you have any outdoor fields or courts?
3. Do you have any pools or water activities?
Please enter a number greater than or equal to 0.
5. Is there a restaurant on premises?
7. Are cooking surfaces properly protected from fire exposures?
8. Is alcohol sold on premises?
Since you answered “Yes”, please complete Liquor Liability application at the end of this form
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
14. If Steel
16. Do you have solar panels?
Please enter a number from 1800 to 2026.
18. Provide details on when the following were updated:
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Please enter a number from 0 to 100.
22. Is there a Central Fire Alarm?
23. Is there a Central Burglar Alarm?
24. Is there Video Camera Surveillance?
If Yes, inside including playing surface?
If Yes, outside including parking lot?
All/limits values below should be 100% estimated Replacement Cost value
Please enter a number greater than or equal to 0.
28 b. Included in Bldg limit?
Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
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35. Is the equipment owned or leased?
Please enter a number greater than or equal to 0.
37. Is the Business Income Limit 100% of the Gross Revenue?

V. Exposure & Risk Management

1. Does the facility host its own leagues?
2 a. Does the facility rent or lease to any other leagues, groups or organizations (for practices/games, parties, special events, shows, pro/semi-pro teams)?
2 b. If yes, is the facility named as additional insured?
3. Are any special events (concerts, MMA, dog shows, etc.) planned at the facility?
Please enter a number greater than or equal to 0.
6. Does the facility host events at locations other than the main location?
7. Are there any batting cages on the premises or brought on the premises temporarily?
If yes, please complete Batting Cage supplement application at the end of this form.
8. Are there any amusement rides on the premises or brought on the premises temporarily?
9. Are there any air inflatable structures on the premises or brought on the premises temporarily?
If yes, please complete Inflatable supplement application at the end of this form.
10. Are there any rock-climbing walls on the premises or brought on the premises temporarily?
11. Are there any children’s play structures on the premises or brought on the premises temporarily?
12. Do you have any skate park or BMX operations on site?
13. Do you have childcare facilities on site?
14. Does the facility subcontract out any of the following?
15. If yes, is the facility named as additional insured?
16. Does the facility rent or repair sports equipment?
17. Is the named insured involved in the sale or distribution of any products?
18. Are staff members trained in CPR and first aid?
19. Does the facility have an AED?
22. Are players required to wear protective equipment?
23. Is a log kept of all incidents/injuries that are reported?
24. Is there a system in place for obtaining certificates of insurance when applicable?
25. Do you have written emergency procedures?
26. Are rules posted conspicuously and enforced at all times?
27. Are all participants/parents required to sign a Waiver and Release of Liability?
30. Are facility inspections (including restrooms, parking lots) done regularly?
31. Is a log kept of inspections and maintenance performed?
32. Is any part of the facility, other than the parking lot, accessible after hours?
33. Is the parking lot well-lighted and patrolled?
34. Do you have an employee manual?
35. Does the facility employ any licensed/certified personal trainers, physical therapists, or other professional staff (i.e., dieticians, nutritionists, chiropractors, massage therapists)?
36. Are any referees or coaches employees of the facility?
37. Are referees required to complete a training or recertification process?
38. Does the facility use a third-party referee assignor?
39. Are there construction operations on site?

VI. For Abuse & Molestation coverage, please complete the following section

1. Does the employment and volunteer application include questions about whether the individual has ever been convicted of any crime, including sex-related or child-abuse related offenses?
2. Does the facility have any volunteers?
3. Do you routinely request and receive background Checks on the following?
Employees?
Volunteers?
4. Do you discuss (at staff/volunteer orientations) sexual abuse, including how to recognize the signs, what to do if a member reports someone molested him/her, peer-to-peer abuse concerns?
5. Do you have a written crisis management plan in place for dealing with members, employees, victims, parents, authorities, and media if you have an incident of abuse?
6. Have you had an incident which resulted in an allegation of physical or sexual abuse?
Concussion protocol questions
7. Does the facility have concussion awareness and training protocols in place?
8. Is the facility in compliance with all state laws relating to concussion protocols?
10. Do the facility employees/coaches (in charge of sports activities) and refs/officials complete concussion awareness training?

VII. For Hired and Non-owned Auto Liability, please complete the following section

1. Does the facility have any company owned automobiles?
2. Do you allow employees to use their own personal vehicles for your business purposes?
Please enter a number greater than or equal to 0.
c. Do you obtain Motor Vehicle Reports?
3. Does your facility transport participants (for camp, leagues or other activities)?
Please enter a number greater than or equal to 0.

VIII. For Employee Benefits Liability, please complete the following section

Please enter a number greater than or equal to 0.
3. Are employees required to sign a form accepting or rejecting a benefit program?

Additional Supplemental Applications


If you answered “Yes” to batting cages, inflatables, and/or sale of alcohol on premises, please complete the required Supplemental Application.

APP SUPPLEMENT Batting Cages
APP SUPPLEMENT Inflatables
APP SUPPLEMENT Liquor Liability
Row ID Named Insured Insured Signature Date Actions
       
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Maximum number of entries reached.

Row ID Insured’s Name Insured’s Signature Date Actions
       
There are no Entries.

Maximum number of entries reached.

Applicant Name Row ID E-mail Contact Person Applicant Signature / Full Legal Name Actions
         
There are no Entries.

Maximum number of entries reached.

Please upload any of the following that apply to your facility:
  • Participant waiver
  • Rental agreement
  • Abuse prevention plan
  • Concussion protocols
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 6.

    Fraud Warning and Certification

    Fraud Warning:
    Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
    I hereby certify that to the best of my knowledge and belief the information provided is true and correct and that no information which materially affects this insurance has been withheld:
    Consent(Required)
    Monument Sports Contact Information:
    1365 Overbrook Road, Suite 1, Richmond, VA 23220
    Phone: (804)-354-9020 or (866)-674-1234
    Fax: (866)-352-1401
    msg@monumentsports.com