Fillable Exercise and Health Studio and Personal Trainer Supplemental (RT Specialty)

Fill Online, Printable, Fillable, Blank Exercise and Health Studio and Personal Trainer Supplemental (RT Specialty) Form

Use Fill to complete blank online RT SPECIALTY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Exercise and Health Studio and Personal Trainer Supplemental (RT Specialty)

On average this form takes 48 minutes to complete

The Exercise and Health Studio and Personal Trainer Supplemental (RT Specialty) form is 4 pages long and contains:

  • 2 signatures
  • 48 check-boxes
  • 161 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your RT Specialty forms online.

BROWSE RT SPECIALTY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Exercise and Health Studio and Personal Trainer Supplemental Application
(Complete in addition to ACORD General Liability Application)
Name of Applicant:
Web site Address:
Location Address:
1. Description of operations: (Check all that apply.)
Aerobics Massage Parlor Pilates Swimming Instruction
Cheerleading Instruction Masseuse Racquet Club Tai Chi
Dance Instruction Personal Trainer Spa Weight Lifting Gym
Exercise Equipment Physical Therapist Swim Club Yoga
Gymnastics Instruction Other:
2. How long has applicant been in business?
3. Sexual and/or Physical Abuse Coverage limits:
$25,000 Per Claim/$50,000 Aggregate
$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
Masseuses
Personal trainers
Physical therapists
Swim instructors
Other (describe):
Total number of employees/contractors
Number of employees/contractors trained in CPR
6. For Independent Contractors:
Do independent contractors provide certificates of insurance? .................................................................. Yes No
Is applicant included as an additional insured on independent contractors’ policy? ................................... Yes No
Limits the independent contractors are required to carry:
GLS-APP-20s (8-11) Page 1 of 4
Submit Here
7. Is all equipment inspected regularly? ............................................................................................. Yes No
Is inspection documentation maintained? ................................................................................................... Yes No
If so, how long?
Has any equipment been built by the applicant? ......................................................................................... Yes No
If yes, attach description.
8. Members’ ages range from to
9. Does membership agreement include a Hold Harmless clause (Liability Waiver) in favor of the
applicant? ...................................................................................................................................................
Yes No
If yes, attach a copy.
10. Other exposures: (Check all that apply.)
Climbing, Tread, or Boulder walls (Please complete Climbing Wall Questionnaire, GLS-APP-47s.)
Day Care
Electrode Machines
Advise details:
Hydro-Massage Beds: Number:
Internet or electronic media communication for exercise or health instruction or consulting
Liquor sales: Receipts: $
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:
Toning Beds: Number:
Trampolines
Advise number, height and diameter:
Describe all off-site activities sponsored:
None of the above
GLS-APP-20s (8-11) Page 2 of 4
11. Indicate any of the following that you provide to your customers:
Blood analysis ....................................................................................................................................... Yes No
Body wraps............................................................................................................................................ Yes No
Medical stress testing ............................................................................................................................ Yes No
Products manufactured by applicant (including but not limited to food & beverage supplements and
vitamins) ................................................................................................................................................
Yes No
Products sold under applicants’ name .................................................................................................. Yes No
Protein diet plans .................................................................................................................................. Yes No
Weight loss or diet clinics ...................................................................................................................... Yes No
None of the above
If yes to any of the above, please describe:
12. 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
Is parking lot well lit?.................................................................................................................................... Yes No
Armed Security Guard on premises? .......................................................................................................... Yes No
Unarmed Security Guard on premises? ...................................................................................................... Yes No
13. 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
14. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
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 Nebraska, Oregon and Vermont.
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.
GLS-APP-20s (8-11) Page 3 of 4
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
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
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 in the third degree.
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 and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and 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 knowingly and with intent to defraud any insurance company 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.
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.
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.
NOTICE TO NEW YORK APPLICANTS (Other than automobile): 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.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK (Automobile): Any person who knowingly and with
intent to defraud any insurance company or other person files an application for insurance containing any materially false
information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person
who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft,
destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or
an insurance company, 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 value of the subject motor vehicle or stated claim for each 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:
GLS-APP-20s (8-11) Page 4 of 4
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Exercise and Health Studio and Personal Trainer Supplemental (RT Specialty)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document