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EXERCISE AND HEALTH STUDIO AND PERSONAL TRAINER SUPPLEMENTAL (Colonial General Insurance Agency, Inc)

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GL-APP-20s (6-18) Page 1 of 5
EXERCISE AND HEALTH STUDIO AND PERSONAL TRAINER SUPPLEMENTAL APPLICATION
(Complete in addition to the ACORD Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
1. Description of operations: (Check all that apply.)
Aerobics Massage Parlor Pilates Swimming Instruction
Anti-Gravity/Aero Yoga Masseuse Racquet Club Tai Chi
Cheerleading Camps/Clinics Personal Trainer Spa Weight Lifting Gym
Cheerleading Instruction Physical Therapist Swim Club Yoga
Dance Instruction Other:
Exercise Equipment
Gymnastics Instruction
2. How long has applicant been in business?
3. Sexual and/or Physical Abuse Coverage limits:
$25,000 Per Claim/$50,000 Aggregate (included)
$50,000 Per Claim/$100,000 Aggregate
$100,000 Per Claim/$300,000 Aggregate
4. Annual gross receipts from all operations: ........................................................................................... $
5. Number of Employees/Contractors:
Employed or Leased Independent Contractors
Certified aerobic instructors
Uncertified aerobic instructors
Dieticians or nutritionists
Masseuses
Personal trainers
Physical therapists
Swim instructors
Other (describe):
Total number of employees/contractors
Number of employees/contractors trained in CPR
GL-APP-20s (6-18) Page 2 of 5
6. For Independent Contractors:
Are certificates of insurance required from all independent contractors? ................................................... Yes No
Is applicant included as an additional insured on independent contractors’ policy? ................................... Yes No
Limits the independent contractors are required to carry: ..........................................................................
7. Members’ ages range from to .
8. Does membership agreement include a Hold Harmless clause (Liability Waiver) in favor of the
applicant? ................................................................................................................................................... Yes No
If yes, attach a copy.
9. Do Physical Therapists provide service to hospitals, clinics, physician’s offices, hospice, con-
valescent/nursing/adult congregate living facilities, jails, prisons or detention centers? ................ Yes No
10. Other exposures: (Check all that apply.)
Altitude mimicking devices (i.e., CVAC)
Climbing, Tread, or Boulder walls (Please complete Climbing Wall Questionnaire, GLS-APP-47s.)
Day Care
Electrode Machines
Advise details:
Foam pits
Hydro-Massage Beds: ........................................................................................................... Number:
Internet or electronic media communication for exercise or health instruction or consulting
Liquor sales: ....................................................................................................................... Receipts: $
Parkour exercise
Retail Sales
Shower/sauna/steam or Jacuzzi facilities
Do the floors for all these areas have non-skid surfaces? .................................................................... Yes No
Snack Bar
Swimming Pool
Number of pools: ..................................................................................................................................
Number of diving boards or platforms: Height:
Number of slides: Height:
Depth of pool markings clearly visible? ................................................................................................. Yes No
Rules posted and life-safety equipment available at poolside? ............................................................ Yes No
CPR-trained individual on duty at all times? ......................................................................................... Yes No
Are all swimming pools, wading pools, hot tubs and spas in compliance with the federal Virginia
Graeme Baker Pool and Spa Safety Act? ............................................................................................. Yes No
Tanning Beds, Booths and Spray-on Booths: ......................................................................... Number:
Goggles provided? ................................................................................................................................ Yes No
Are all timers operated by an attendant? .............................................................................................. Yes No
Are tanning units Underwriters Laboratory approved? ......................................................................... Yes No
Are all tanning units manufactured in the United States? ..................................................................... Yes No
Are all tanning units disinfected after each use? .................................................................................. Yes No
Do signs prohibit use of tanning units during pregnancy or if on medication? ..................................... Yes No
Are customers advised to remove contact lenses? .............................................................................. Yes No
Are waivers signed by each customer? ................................................................................................ Yes No
If customer is under the legal age, is the parent required to also sign waiver? .................................... Yes No
Tennis/Racquetball/Handball/Squash Courts: ......................................................... Number of courts:
GL-APP-20s (6-18) Page 3 of 5
Toning Beds: ........................................................................................................................... Number:
Trampolines
Advise number, height and diameter:
11. Other exposures (continued): (Check all that apply.)
Describe all off-site activities sponsored:
None of the above
12. Indicate any of the following the applicant provides:
Blood analysis
Body wraps
Medical stress testing
Products manufactured by applicant (including, but not limited to, food and beverage supplements and vitamins)
Products sold under applicants’ name
Protein diet plans
Weight loss or diet clinics
None of the above
If yes to any of the above, please describe:
13. Is all equipment inspected regularly? ..................................................................................................... Yes No
Is inspection documentation maintained? ................................................................................................... Yes No
If yes, how long? .........................................................................................................................................
Has any equipment been built by the applicant? ......................................................................................... Yes No
If yes, attach description.
14. Premises:
Hours of operation from to .
Are staff members always present when clients are on the premises? ...................................................... Yes No
If no, advise monitoring and security requirements when staff is not present:
Is access to any operations limited or restricted (i.e., pool, sauna, tanning units, etc.)? ............................ Yes No
If yes, explain in detail:
Is parking lot well lit?.................................................................................................................................... Yes No
Armed Security Guard on premises? .......................................................................................................... Yes No
Unarmed Security Guard on premises? ...................................................................................................... Yes No
15. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?.................................................................................................... Yes No
If yes, describe:
16. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
GL-APP-20s (6-18) Page 4 of 5
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or state-
ment as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or con-
ceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
GL-APP-20s (6-18) Page 5 of 5
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information, or conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is
a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim
for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: Date:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: Date:
Agent Email: Preferred Method of Correspondence Email Fax Mail
Applicant Email: Preferred Method of Correspondence Email Fax Mail
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Completed 22 August 2020

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