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The Fitness Industry Combined Insurance Cover
Online Application Form

Name of Proposer
Trading Name
Business Address
Correspondence Address
(if different)
Contact Name
Tel. No.    Fax    Mobile   
Email
Business Description
Date Business Established
Is company UK registered? Yes   No
Are you a member of:
The Fitness Industry Association? Yes   No
Any other association? Yes   No
If so please state which
Facilities provided: To select more than one of the following please hold the 'Ctrl' key down while clicking on the required options.

If 'Other' please type details here:
SECTION 1
(i) Buildings Sum Insured £
(ii) Tenants Improvements £
(iii) All other General Contents excluding computers £
(iv) Computers £
(v) Frozen Foods (limit per freezer £2,500)Number of Freezers
(vi) Stock in Trade
1. Clothing, Footwear £
2. Food & Beverages £
3.All other Stock £
(vii) Business Equipment away from the premises £
SECTION 2 Business Interruption£
Select One Basis of Cover:
Indemnity Period Required: Months
Do you require Loss of Licence Indemnity?     Value:   
Date licence issued   
Has there been any opposition / complaint / refusal?   
State any Licence Restrictions / Conditions   
SECTION 3 Asset & Revenue Protection
Do you require terrorism cover? Yes   No
SECTION 4 Legal Liabilities
Estimated Turnover in the next 12 months£
Third Party Indemnity Limit you require:
Annual Payroll for all:
Non-manual principals, managers, clerical staff, including instructors, teachers.		£
Others, e.g. Manual£
Do you provide any treatments such as massage, beauty treatments or other therapies? If yes, please see list in the brochure of those treatments automatically covered under your policy.
Do you allow anyone under the age of 18 to use the gym/fitness centre?
If YES, please state:
How many members are under 18
The age of the youngest member
What percentage of you Turnover is applicable to:
Café / Bar / Restaurant Sales%
Retail and Leisure wear Sales%
Hairdressing, beauty and other treatments%
SECTION 5 Employee and member benefits
Do you wish to extend cover to include Occupational Personal Accident Insurance?
Has any employee been absent from work for more than 7 days,
due to accident or illness in the last 3 years?
If YES, enclose details
Number of employees in each category
Principals and Managers Instructors and Supervisors
other non-manual staff Caretakers, Cleaners etc
Do you wish to extend cover to include Members Personal Accident Insurance?
SECTION 6 Legal Expenses
Your policy automatically includes Legal Expenses Insurance following certain events. Would you like a quotation for full commercial legal expenses cover?
SECTION 7 Employee Dishonesty
Do you wish to extend cover to include theft by employees? If a limit above £10,000 is required please contact us.
SECTION 8 Directors & Officers Liability
Do you wish to extend cover to include Directors & Officers?
Limit of Indemnity
General Information
Are your premises of Standard Construction:
i.e. Brick / Concrete / Tile / Slate
Timber / Felt / other, give details
Do you share your building? If yes how is the rest of it occupied?
What floor/floors do you occupy?
Estimated number of members in the next 12 months
Security protections at your premises:
Do your premises comply with the Minimum Security Requirements below?
Minimum Security Requirements
  1. Final exit door and internal doors giving access to parts of the building not occupied by the proposer should be fitted with a 5-lever mortice deadlock.
  2. All ground floor, basement and accessible opening windows should be fitted with key operated window locks.
Do you have a NACOSS approved alarm?      Is signalling:   
Name of alarm maintenance company:   
Do all Staff have an induction course including health & safety procedures?
Do all staff have qualifications for the activities they instruct?
Has any insurer declined a proposal, cancelled your policy or cover or imposed any special terms?
If YES, give details
Have you or any of your principles:
(a) Ever been convicted of, or is any prosecution pending for, any offence involving dishonesty of any kind.
(e.g. involving fire, fraud, theft or handling stolen goods)?
(b) Ever been declared bankrupt, the subject of bankruptcy proceedings or made arrangements with creditors, either in a personal capacity or in connection with any company, business or firm in which any of you have been involved?
If YES to (a) or (b) please give full details
Name of existing Insurers:   
Current Insurance Premium:   £
Renewal Date:   
Do you wish to pay monthly (Full details will be provided)   
Have you suffered any losses in the last 5 years?   
If YES please provide information:
Date:    Type:    Amount:   £
Date:    Type:    Amount:   £
Date:    Type:    Amount:   £

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John Ansell & Partners Limited
Insurance Brokers, Overseas House, 19-23 Ironmonger Row, London EC1V 3QN
Telephone: 020 7251 6821 | Fax: 020 7490 0708 | e-mail: enquiries@ansell.co.uk
 
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