Client Application

Business Entity Name:*

Affiliate or DBA Name (If Applicable):

Entity Type:*

Contact Name:*

Phone*

Email*

Mailing Address*

Street Address City State ZIP Code

Location Address*

Street Address City 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:*

OPERATIONS

Is the facility open 24 hours?*

Yes
No

If Yes, PLEASE CONTACT US FOR GUIDELINES

Do members have access outside of regular business hours?*

Yes
No

Do you have exposure to child sitting services?*

Yes
No

If yes, please answer the following questions:

Criminal and background checks are performed on all potential employees having exposure to or responsibility for children

Yes
No

No children under 6 weeks old accepted

Yes
No

Children are required to be signed in and signed out

Yes
No

A member signing in a child must be on premises at all times

Yes
No

Do you have exposure to martial arts?*

Yes
No

If yes, any off premise exposure?

Yes
No

Do you offer CrossFit Kids?*

Yes
No

Are there workouts done outside of your location?*

Yes
No

If so, what is the percentage?:

Will you be hosting any events or competitions this year?*

Yes
No

If yes, PLEASE CONTACT US FOR GUIDELINES

Is 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?*

Yes
No

All Criteria must be answered True to be eligible for this program

1. 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 CARRIER

PROPERTY

Do you own the building you occupy?*

Yes
No

If yes, PLEASE CONTACT OUR OFFICE FOR ADDITIONAL APPLICATION

Do you have a central alarm system?*

Yes
No

**Please note: Theft coverage will be excluded from your insurance policy if you do not have a central alarm system.

Have any updates been made to your building?*

Yes
No

If yes, please list the year updates were performed below.

If roofing updates, what year?

If electrical updates, what year?

If plumbing updates, what year?

If heating updates, what year?

Do you want property coverage for your fitness and office equipment?*

Yes
No

Current 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 $500

Do you want business income coverage?*

Yes
No

What 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?*

Yes
No

(Coverages named below)

COVERAGE	LIMIT OF INSURANCE	DEDUCTIBLE
Computer Equipment	$25,000	$500
Outdoor Signs	$25,000	$500
Glass	$5,000	$500
Back-Up of Sewers and Drains	$10,000	$500

INSPECTION ACKNOWLEDGEMENT

I 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 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.

Signature

Your Title*

Today's Date:*

Client Application