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Client Application - March 2019 Business Entity Name:*Affiliate or DBA Name (If Applicable):Entity Type:*IndividualCorporationPartnershipLLCOtherContact Name:*Phone*Email* Mailing 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 Location 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:*Annual Gross Sales:*Year Business Started:*Number of Members:*Age Range of Clientele:*Number of Trainers:*Hours of Operation:*OPERATIONSIs the facility open 24 hours?*YesNoIf Yes, PLEASE CONTACT US FOR GUIDELINESDo 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?:Will you be hosting any events or competitions this year?*YesNoIf yes, PLEASE CONTACT US FOR GUIDELINESIs there a working and functional automatic external defibrillator (AED) on the insured premise and are trainers are properly trained to use an AED in the event of need?*YesNoAll 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 trainers are required to be certified/licensed* True False 3. All trainers are required to be CPR certified* True False 4. All equipment is inspected regularly and Service logs are maintained* True False 5. No chiropractic, physical therapy, rehabilitation services, acupuncture, electrolysis or hair removal, or any type of body container services or similar professional services are performed by your business* True False 6. No manufacturing or altering the packaging of any diet aids, vitamins, supplements or similar products* True False 7. No actual or alleged incidents have arised regarding molestation or abuse* True False 8. Background checks are performed on all Trainers* True False 9. No medical services, blood analysis, stress testing 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 12. No bouldering or rockclimbing walls are on the premises* True False LOSS HISTORY- BOTH GENERAL LIABILITY AND PROPERTY** UNLESS A NEW VENTURE, PLEASE PROVIDE 3 YEAR LOSS RUNS FROM YOUR PREVIOUS CARRIERPROPERTYDo you own the building you occupy?*YesNoIf yes, PLEASE CONTACT OUR OFFICE FOR ADDITIONAL APPLICATIONDo you want property coverage for your fitness and office equipment?*YesNoCurrent value of ALL fitness and office equipment*Property will be valued by replacement cost as long as insured to 80% of total value. Property deductible per loss is $500Do you want business income coverage?*YesNoWhat is the square footage you occupy?*What year was your space built?*What construction material is your building made of?*Would you like to purchase the Optional Property Extension endorsement?*YesNo(Coverages named below) COVERAGE LIMIT OF INSURANCE DEDUCTIBLE Computer Equipment$25,000$500Outdoor Signs$25,000$500Glass$5,000$500Back-Up of Sewers and Drains$10,000$500INSPECTION ACKNOWLEDGEMENTI understand that the insuring carrier shall be permitted, but not obligated, to inspect an insured's property and operations for underwriting purposes at any time. Neither the right to make an underwriting inspection nor the making thereof nor any report thereon shall constitute an undertaking, on behalf of or for the benefit of any insured, or other, to determine or warrant that such property or operations are safe or healthful, or in compliance with any standards, rules or regulations. Underwriting inspections when conducted are for the sole purpose of determining and/or improving the insurability of certain property and operations and not safety. I also understand that an insured is solely responsible for the safety of its facilities and operations and shall not rely upon any underwriting inspections to determine the safety of its facilities or operations and shall not diminish or forego its own safety practices and procedures.APPLICANT WARRANTY STATEMENTThe 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.Signature*Your Title*Today's Date:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 This iframe contains the logic required to handle Ajax powered Gravity Forms.