[U.S.] Fitness Instructor Application

Request Date    09/10/2010 07:52:21 AM

Named Insured
Address of Insured
  City
  State
  Country
  Zip code
Form of Business
Contact Name
  Telephone Number
  Fax     
  Email
Organization Type
Event Location(s)/Address(es)
Are you (or applying on behalf of) an insurance agent/broker? 
Agent/Broker Name
  Telephone Number
  Fax number
  E-mail
 
Please describe the operations/activities to be insured: 
Sport/Activity
Level
Number of playing days including games, practices and tournaments
(for period of coverage)
Number of Male Participants 12 and younger
Number of Male Participants 13-15
Number of Male Participants 16-18
Number of Male Participants 19 and older
 
Number of Female Participants 12 and younger
Number of Female Participants 13-15
Number of Female Participants 16-18
Number of Female Participants 19 and older
 
Number of Teams
If cover for another Sport/Activity is sought, please check next next
 
What type of security will you be using?
Maximum number of spectators at any individual event or location
Estimated Total Gross Receipts $
 
REQUESTED EFFECTIVE DATE (Activity Start Date):
REQUESTED EXPIRY DATE (Activity End Date):
 
Total Number of Actual Exposure Days (total number of playing days
including games, practices and tournaments)
Average Number of Participants per Exposure Day
Desired Acc Med Deductible
Desired Acc Med Benefit

Will you be using any, pyrotechnics, or use of mechanical devices that will be ridden (excluding sporting equipment)? 
If yes, please describe, in detail, any use of special effects, pyrotechnics, or use of mechanical devices, etc.: 
Does any volunteer, owner, coach or official have a criminal record, or has ever had a criminal record? 
If yes, please explain: 
Have you had any claims in the past five (5) years? 
If yes, please describe any losses you have incurred over the past five (5) years, and provide insurance company loss runs: 
Have you ever filed for bankruptcy? 
If yes, please explain: 
Have you ever had insurance Cancelled, or Non Renewed for any reason? 
If insurance has been declined or cancelled, please explain: 
Does the applicant have risk exposure within the State of California? 
 

Please note that eligibility for insurance coverage under this programme requires that the applicant
  • utilize the client waiver available here (to download, right click and select 'Save Target').

    • Individuals Covered
    All players, managers or coaches of the Policy holder
     
    Activities Covered
    While participating as a member of the team in a scheduled game, an official tournament game, or in a practice session of the team; or travelling directly to or from a game or practice session as a member of the team
     
    Rates Contemplate
    All policies are subject to minimum premiums
    All standard terms, conditions and exclusions apply
    Coverage cannot be back dated
     
    Coverage Limits
      General Liability: $1,000,000 Per Occurrence / $2,000,000 Aggregate
      Accident Medical: $5,000 AD&D / $25,000 (or as selected) Acc Med Benefit
     

    Does the applicant require certificates of insurance for Additional Insureds? 

    Optional Liability Coverages (Additional Premium Will Apply)
    Please select desired optional coverage(s).
     
    Abuse/Molestation Coverage
    This endorsement covers the defense of the accusation against a staff member.
    Per Occurrence/Aggregate Coverage for claims of Abuse/Molestation can be added for an additional premium of:
     
    $50,000/$100,000 Abuse/Molestation $1,250.00*
    $100,000/$500,000 Abuse/Molestation $1,875.00*
    $500,000/$1,000,000 Abuse/Molestation $2,500.00*
    $1,000,000/$1,000,000 Abuse/Molestation $2,815.00*
     Abuse/Molestation Coverage NOT REQUIRED
    *Fully Earned at Policy Inception. Additional Premium amount may be more, depending on number of participants.
     
    Hired/Non Owned Auto Liability Coverage
    $1,000,000 Hired/Non Owned Auto Liability Coverage can be added for an additional premium/taxes/fees of:
     
     $1,110.00 (fully earned at inception. May be more, depending on cost of hire.)
             If Hired/Non Owned Auto Liability Coverage is Required, please complete the
             'Hired/Non Owned Auto Liability Coverage Section', below.
     Hired/Non Owned Auto Liability Coverage NOT REQUIRED
     
    Excess Liability Coverage
    Follow-Form Excess Liability Coverage can be added for the following limits and premiums/taxes/fees:
     
    $1,000,000/$1,000,000 Excess Liability $1,110.00* (Total Liability Coverage Amount $2M/$3M)
    $2,000,000/$2,000,000 Excess Liability $2,210.00* (Total Liability Coverage Amount $3M/$4M)
    $3,000,000/$3,000,000 Excess Liability $3,310.00* (Total Liability Coverage Amount $4M/$5M)
    $4,000,000/$4,000,000 Excess Liability $4,410.00* (Total Liability Coverage Amount $5M/$6M)
    $5,000,000/$5,000,000 Excess Liability $5,510.00* (Total Liability Coverage Amount $6M/$7M)
     Excess Liability Coverage NOT REQUIRED
    *Fully Earned at Policy Inception. Additional Premium amount may be more, depending on coverage period.



    DECLARATION
    To the best of my knowledge and belief all statements made in this Application for Insurance are true. Signing of this document does not bind the Applicant to complete the insurance, but it is agreed that this Application shall be the basis of the contract, should a policy be issued.
     
     
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