Corporate and DBA Name of Business
*
Name (First & Last)
*
Telephone
*
Email
*
Preferred Contact Method
Number of Members
*
Number of Holes
*
Number of Employees
*
Membership Dues/Initiation Fees
*
All Other Fees (Greens, Golf Carts, Tournaments, etc.)
*
Pro Shop Merchandise Revenue (if owned)
*
Snack Bar/Restaurant Receipts (excluding Liquor)
*
Liquor Sales
*
If HOA, Number of Members/Homes
Number of Rounds Played per Year
*
Amenities offered (check all that apply)
*
A separate application may be required dependent upon amenities offered
Other (Please provide a brief description of other amenities):
Is the "Golf Pro" an:
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Is the Pro Shop:
*
If operated Independently, does club obtain a Certificate of Insurance from the Pro?
Yes
No
Is there a Risk Transfer program in place including obtaining Certificates of Insurance and favorable hold harmless contracts from all vendors?
*
Yes
No
Does the club have a formal, written safety program?
*
Yes
No
Have membership by-laws and guidelines been reviewed and approved by legal counsel within the last 3 years?
*
Yes
No
Does the insured perform weekly inspections of the golf course including cart path conditions, bridges, road crossings?
*
Yes
No
Does the golf course have known presence of any dangerous animals and/or reptiles (i.e. alligators)?
*
Yes
No
If yes, what controls are in place to protect golfers?
Distance to closest fire hydrant:
Distance to closest Fire Department:
The Clubhouse is protected by
*
Select all that apply
Does the club have back-up generators for use in the event of a power outage?
*
Yes
No
If yes, what systems are connected to the back-up generators?
Other (please describe):
If smoking is permitted are there designated smoking areas with proper disposal receptacles?
Yes
No
What type of roof is on the clubhouse?
*
Other (please describe)
Are any buildings closed down or unoccupied during a period of time where frozen temperatures are possible?
*
Yes
No
Is the thermostat set at greater than 40 degrees Fahrenheit for any unoccupied building?
Yes
No
Is staff assigned to regularly inspect unoccupied premises/building and document the inspection?
Yes
No
Are temperature monitoring syestems installed in unoccupied buildings to monitor and report temperature loss?
Yes
No
Are heating, plumbing, and water systems (including sprinkler systems) inspected annually, including formal documentation of winterization process for all buildings?
Yes
No
Are removable structures such as awnings and tents taken down in advance of a winter storm?
Yes
No
Do you promptly initiate snow removal from roofs after snow and ice accumulation to prevent roof structure damage or collapse?
Yes
No
Total Number of Riding Golf Carts
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Golf Carts are:
Where are the golf carts stored?
*
If cartsare stored in a section of the Clubhouse, is the storage area fully sprinklered?
Yes
No
If electric carts, does the Cart Barn Building have proper ventilation?
Yes
No
Is the building equipped with Central Station Smoke/Heat Detection?
Yes
No
Is the building equipped with Central Station Burglar Detection?
Yes
No
Does the applicant require annually-signed Golf Cart Rental Agreement by members?
Yes
No
If yes, does the agreement require the member to assume all liability related to golf cart use for their guests throughout the year?
Yes
No
Does the club have a lightning warning and notification system in place?
Yes
No
If yes, please describe
In what building is the grounds equipment stored?
*
Is the building equipped with Central Station Smoke/Heat Detection?
Yes
No
Is the building equipped with Central Station Burglar Detection?
Yes
No
Does the club have a regular maintenance program in place?
Yes
No
Does the club routinely replace older equipment?
Yes
No
Is the snack bar or restaurant operated by
If concession, does lesee provide Certificates of Insurance naming club as Additional Insured?
Yes
No
Is the extinguishing system over the cooking facilities UL 300 compliant?
Yes
No
Does the system cover Deep Fat Fryers?
Yes
No
Is the system serviced at-least semi-annually?
Yes
No
If no, how frequent?
Are hood and duct filters cleaned by insured at least weekly?
Yes
No
If no, how frequent?
Does club require Employees to have TIPS or similar alcohol awareness training?
Yes
No
Are written procedures in place regarding the proper serving of alcohol?
Yes
No
Does the club have a "Call A Cab' program in place?
Yes
No
Number of pools on premises:
Are you compliant with The Virginia Graeme Baker Pool and Spa Safety Act?
Yes
No
Is the pool fenced?
Yes
No
Does the fence have a self-latching gate?
Yes
No
Are there any diving boards?
Yes
No
If yes, how many diving boards?
Height of diving board(s) in meters
Depth of Pool at entry from the diving board(s)
Are lifeguards on duty?
Yes
No
If no, is a sign posted "Swim At Your Own Risk"?
Yes
No
If no, is there an Emergency Phone within 100' of the pool area?
Yes
No
Does pool have visible depth markers?
Yes
No
What is the deepest/highest depth of pool?
Is the pool locked to deny normal access during non-working hours?
Yes
No
Is there a sliding board?
Yes
No
If yes, height and type of slide
Are slide/diving activities separate from normal pool?
Yes
No
Is there a swim team associated with the club?
Yes
No
Is there a dive team associated with the club?
Yes
No
Does the club perform criminal and child abuse background checks on employees associated with the swim/dive team?
Yes
No
Do you have Dwellings, Rental Properties, Guest Rooms or Employees' Quarters?
Yes
No
If yes, please describe the use of the property:
If there are employee quarters, advise where they are and how many employees occupy them:
If the club has any of the above habitational property, do they have any of the following:
Select all that apply
If there is lodging/guest quarters, what is the total number of rooms available?
Are rooms available to members and their guests only?
Yes
No
Does the club provide any babysitting services?
Yes
No
If yes, age of children?
What is the length of stay provided?
What is the maximum number of children allowed?
Does the club perform a criminal background check on all caregivers?
Yes
No
Does the club perform a child abuse background check on all caregivers?
Yes
No
Does the club operate a day camp?
Yes
No
What is the counselor to children ratio? (i.e. - 1 counselor to 6 children)
Number of children in the following age groups:
0-5
6-10
11-14
Available to members' children only?
Yes
No
Any field trips off premises?
Yes
No
If yes, please describe:
Does the club perform a criminal background check on all counselors?
Yes
No
Does club perform a child abuse background check on all counselors?
Yes
No
How long do the day camps run? (i.e. - Last 3 weeks of July)
What are the daily hours? (i.e. - 9 to 2 Monday through Friday)
Does the club provide any transportation?
Yes
No
If yes, please describe:
If no, who does?
Is there a contract in place?
Yes
No
Has the applicant confirmed proper Insurance is in place?
Yes
No
What is the limit of Insurance purchased?
Is the applicant named as an Additional Insured on the 3rd party's auto policy?
Yes
No
Does the club have any guards?
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Yes
No
If yes, are they employees or vendors?
Yes
No
If yes, are they armed?
Yes
No
Additional Notes:
