8700 EAST NORTHSIGHT BLVD., SUITE #200 • SCOTTSDALE, ARIZONA • 85260-3669 PHONE 800-243-1782 • FAX 480-951-9722
Applicant’s Name: _____________________________ Location Address: _____________________
Mailing Address: _____________________________ _____________________
_____________________________ _____________________
Operation: Ex
ercise Equipment Free-weight Lifting Aerobics Dance Studio Personal Trainer
Physical Therapist Masseuse Spa Massage Parlor Gymnastics School
Annual gross receipts from all operations: $_________________
Is all equipment inspected regularly? Yes No
Is inspection documentation maintained? Yes No If yes, how long? ________
Do you use equipment that you have built? Yes No If yes, attach a description.
Does membership agreement include a Hold Harmless clause (Liability Waiver)? Yes No If yes, attach a copy.
Members age range from __________ to __________.
Other operations:
Day Care Pro Shop Snack Bar Climbing Wall If yes, how high? ________
Swimming Pool Number of diving boards___________ Height ________ ft.
Rules posted? Yes No Life saving equipment? Yes No
Toning beds Number __________
Tanning beds Number __________ Are goggles provided? Yes No
Are all timers operated by an attendant? Yes No Are beds U.L. approved? Yes No
Are all beds manufactured in the US? Yes No Are all beds cleaned after each use? Yes No
Do signs prohibit use of the beds during pregnancy or if on medication? Yes
No
Tenn
is Courts/Racquetball Courts/Handball/Squash Courts/Basketball Courts Number __________
Describe off-site activities you sponsor: _______________________________________________________________________
Please indicate any of the following that you provide to your customers:
Protein Diet Plans Body wraps – other than organic Blood Analysis Stress Testing
Weight loss or diet clinics Products manufactured by or sold under club’s name Health Supplements
Premises exposures: Hours of operation from ____________ to ____________
Is parking lot well lit? Yes No Security Guard on premises? Yes No
Any trampolines? Yes No Any electrode machines? Yes No
Shower/sanua/steam Jacuzzi facilities? Yes No Do the floors for these areas have non-skid surfaces? Yes No
Number of Employees Employed Leased Independent Number of Employees Employed Leased Independent
Certified aerobic instructors Personal trainers
Uncertified aerobic instructors Masseuses
Total number of employees Other: (describe)
Number of employees trained in CPR
If any independent contractors, are they licensed and insured? Yes No
Do they provide certificates of insurance? Yes No
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
containing false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime. This application does not bind any of the parties to complete the insurance transaction.
_______________________________ ______________________________ _________________
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Producer’s
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Date
EXERCISE & HEALTH STUDIO SUPPLEMENT
(Include Acord application)
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