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Client Application Affiliate Name:*Entity of Business:*IndividualCorporationPartnershipLLC OtherLocation Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Description of Operations:What year did the business start?:General Liability SectionLimit $1,000,000 / $3,000,000 Abuse & Molestation Liability Limit: $100,000 / $300,000 Annual Gross Sales:Number of Members:Hours of Operations:Number of certified trainers:Age range of clientele:Is the facility open 24 hours?YesNoIf yes, do you have a Fitness Staff certified in CPR on duty all hours of operation?YesNoDo members have access outside of regular business hours?YesNoDo you have exposure to child sitting services?YesNoIf yes, please answer the following questions:Criminal and background checks are performed on all potential employees having exposure to or responsibility for childrenYesNoNo children under 6 weeks old acceptedYesNoChildren are required to be signed in and signed outYesNoA member signing in a child must be on premises at all timesYesNoDo you have exposure to martial arts?YesNoIf yes, any off premise exposure?YesNoDo you offer CrossFit Kids?YesNoAre there workouts done outside of your location?YesNoIf so, what is the percentage?:Do you sponsor any outside events?YesNoIf so, how many per policy term?:General Liability continued – All Criteria must be answered True to be eligible for this program1. All members and guests using the facility are required to sign a Release/Waiver of Liability True False 2. All Personal Trainers are required to be certified True False 3. All fitness personnel are required to be CPR certified True False 4. Service logs are maintained on all equipment True False 5. No chiropractic, physical therapy, rehabilitation services or similar professional services by direct employees and all professionals renting space from the insured are required to carry their own insurance and name the Applicant as an Additional Insured. True False 6. Applicant does not manufacture or alter the packaging of any diet aids, vitamins, True False supplements or similar products True False 7. No actual or alleged incidents regarding molestation or abuse True False 8. No type of acupuncture services, electrolysis or hair removal services, body wrapping services or any type of body container services are provided by your center True False 9. No medical services, blood analysis, stress testing, weight loss or diet clinic exists True False 10. No bankruptcies, tax or credit liens against the applicant in the last 5 years? True False 11. Coverage has not been cancelled or non-renewed in the last 3 years (not applicable in Missouri) True False If False, what was the reason for previous cancellation?:Loss HistoryLiability Claims None, or provide detail below. YearStatusOpenClosedIncurredDescriptionLiability Year 2Liability Status 2OpenClosedLiability Incurred 2Liability Description 2Liability Year 3Liability Status 3OpenClosedLiability Incurred 3Liability Description 3Property Claims None, or provide detail below. YearStatusOpenClosedIncurredDescriptionPropertyYear2PropertyStatus2OpenClosedPropertyIncurred2PropertyDescription2PropertyYear3PropertyStatus3OpenClosedPropertyIncurred3PropertyDescription3Property SectionDo you want property coverage?YesNo (If selected, an additional $250.00 charge will apply)Construction: Frame Joisted Masonry Non-Combustible Masonry Non-Combustible Modified Fire-Resistive Fire-Resistive Other Protection Class:Coverage Includes: Requested Cause of Loss: ☒ Special Requested Valuation: ☒ Replacement Cost Deductible ☒ $500 Coinsurance: ☒ 80% Business Personal Property Limit $20,000 - Included Business Income & Extra Expense Limit $50,000 – Included Optional Coverage: Property Extension endorsement: $150.00 additional premium COVERAGE LIMIT OF INSURANCE DEDUCTIBLE Limited Equipment Breakdown $25,000 $500 Accounts Receivable $25,000 $500 Computer Equipment $25,000 $500 Money and Securities $5,000 $500 Employee Dishonesty $5,000 $500 Outdoor Signs $25,000 $500 Spoilage $25,000 $500 Valuable Papers $25,000 $500 Back-Up of Sewers and Drains $10,000 $500 Do you own the building?YesNo (If No, skip Building Owner Questions below)Building OwnerBuilding Limit: (Additional premium applies)What year was the building constructed?:What is the square footage of the entire structure?Age of roof (yrs):Plumbing updated (yr):Electrical updated (yr):Heating updated (yr):Roof Type:FlatWood ShakeShingleMetalTileSlateOtherPlumbing Type:PVCCopperLeadGalvanizedOtherWhat type of burglar alarm is on the premises?CentralStationLocalNone1. For any building built prior to 1978, 100% of the electric wiring is on functioning and operating circuit breaksN/ATrueFalse2. For any building built prior to 1978, there is no aluminum wiring or knob & tube wiring N/A True FalseN/ATrueFalse3. Functioning and operational fire extinguishers availableTrueFalse4. Functioning and operational smoke detectorsTrueFalse5. Building is a non-standard structure (i.e. bubble, dome, etc.)TrueFalseApplicant’s Warranty Statement: The undersigned represents to the best of his/her knowledge and belief the particulars and statements set forth are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The signing of the Application does not bind the undersigned to purchase the insurance, nor does the review of the Application bind the Company to issue a policy.Contact InformationMailing Address (If different than the location address above): Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address of primary contact: Phone:Inspection Contact Name: Telephone/Email Address:Audit Contact Name:Telephone/Email Address: SignatureToday's Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Title: This iframe contains the logic required to handle Ajax powered Gravity Forms.