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MARTIAL ARTS SCHOOL SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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Martial Arts School
Supplemental Application
Page 1 of 5
11/2009
MARTIAL ARTS SCHOOL SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
• School’s brochure describing activities provided
• Sparring rules
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years
GENERAL INFORMATION
Applicant Name: Effective Date:
Facility Name: FEIN:
Mailing Address: SIC Code:
Contact Phone: Web Address:
1. Names of all instructors along with qualifications:
Instructor Names
Qualifications Certified By Whom?
(Include Belt Rank)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
2. How many of the above are employees or sub-contractors?
Employees: Sub-contractors:
3. Name of art(s) / style(s) that you teach:
4. Name of associations you belong to:
5. Projected maximum number of students you have enrolled at your busiest time of year:
6. Average cost of membership/class:
7. Age range of students: From: years old to years old.
8. Describe floor surface on which classes are taught:
Clear Application
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Martial Arts School
Supplemental Application
Page 2 of 5
11/2009
GENERAL LIABILITY LIMIT OPTIONS
General Aggregate: $2,000,000 $1,000,000 $600,000 $300,000
Products/Completed Ops Aggregate: $2,000,000 $1,000,000 $600,000 $300,000
Personal Inju
ry: $1,000,000
$ 500,000 $300,000 $100,000
Occurrence: $1,000,000 $ 500,000 $300,000 $100,000
Fire Legal: $ 50,000 $ 50,000 $ 50,000 $ 50,000
ACTIVITIES INFORMATION
1. Is there free sparring? Yes No
2. If yes, is it (light contact ) or (full contact )
3. Are sparring rules typed on school letterhead? Yes No
4. Are sparring rules addressed to students and given to all students? Yes No
5. Are sparring rules signed and dated by the school owner? Yes No
6. Do your written rules clearly state that no contact is permitted to the groin or
above the shoulders other than light contact to headgear? Yes No
7. Are kicking motions to head permitted in sparring? Yes No
8. Do you require use of the following protective gear:
• Headgear?
Yes No
• Mouthpieces?
Yes No
• Boots?
Yes No
• Gloves?
Yes No
• Groin protectors for males?
Yes No
• Breast / Chest protectors for females?
Yes No
9. Is there a signed Hold Harmless Agreement on file for each student? Yes No
If yes, are both parents’ signatures required for minors? Yes No
10. Do you offer kickboxing or boxing training? Yes No
Kickboxing Light contact Full contact
Boxing Light contact Full contact
11. Do you participate in tournaments? Yes No
12. Do you sponsor tournaments? Yes No
If yes, provide number of participants:
If yes, attach tournament brochure
13. Do you provide or render acupuncture? Yes No
14. Do you offer weapons training? Yes No
If yes, are weapons “live”? Yes No
If yes, at what belt level does training begin?
Do you teach street fighting? Yes No
Do you offer self defense programs? Yes No
Do you offer weight / strength training? Yes No
ABUSE AND MOLESTATION
1. Does your staff (paid and volunteer) employment application include
questions about whether the individual has ever been convicted of any crime,
including sex-related or child-abuse related offenses? Yes No
2. Does your state permit you to do criminal background investigations? Yes No
If yes, do you routinely request and receive such background investigations? Yes No
3. Do you verify employment related references? Yes No
4. Do you conduct a personal interview? Yes No
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Martial Arts School
Supplemental Application
Page 3 of 5
11/2009
5. Do you have written procedures for dealing with sexual abuse? Yes No
If yes, please attach a copy.
6. Do you have a plan of supervision that monitors staff in day-to-day
relationships with students, both on and off premises? Yes No
7. Has your organization ever had an incident which resulted in an allegation of
sexual abuse? Yes No
If yes, please describe.
Was a claim made against the organization? Yes No
Was the case settled? Yes No
Was the case taken to trial? Yes No
How much money was paid as damages to the victim?
FRAUD NOTICE STATEMENTS
NOTICE TO APPLICANTS: “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 MAY SUBJECT
SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.”
NOTICE TO ALASKA RESIDENTS APPLICANTS: “A PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD
OR DECEIVE AN INSURANCE COMPANY FILES A CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING
INFORMATION MAY BE PROSECUTED UNDER STATE LAW.”
NOTICE TO ARKANSAS RESIDENT 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.”
NOTICE TO ARIZONA RESIDENTS APPLICANTS: "FOR YOUR PROTECTION ARIZONA LAW REQUIRES THE FOLLOWING
STATEMENT TO APPEAR ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM
FOR PAYMENT OF A LOSS IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES."
NOTICE TO COLORADO RESIDENTS APPLICANTS: “IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE,
OR MISLEADING FACTS OR INFORMATION 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 POLICYHOLDER OR CLAIMANT FOR
THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO
A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO
DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.”
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: “WARNING: 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 RESIDENTS APPLICANTS: “ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE,
DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE,
INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.”
NOTICE TO KENTUCKY APPLICANTS: “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, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME.”
Clear Application
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Martial Arts School
Supplemental Application
Page 4 of 5
11/2009
NOTICE TO LOUISIANA RESIDENTS 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.”
NOTICE TO MAINE RESIDENTS 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.”
RESIDENTS OF 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.”
RESIDENTS OF MINNESOTA APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE
IS FACILITATING A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE
OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION
ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.”
RESIDENTS OF NEW MEXICO 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 CIVIL FINES AND CRIMINAL PENALTIES.”
RESIDENTS OF NEW YORK APPLICANTS: “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.”
RESIDENTS OF OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS
FACILITATING A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE
OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF 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 INFORMATION IS GUILTY OF A FELONY.”
RESIDENTS OF OREGON APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT
ANOTHER TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A
FALSE STATEMENT AS TO ANY MATERIAL FACT, MAY BE VIOLATING STATE LAW.”
RESIDENTS OF PENNSYLVANIA APPLICANTS: “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.”
RESIDENTS OF TENNESSEE 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 INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF TEXAS APPLICANTS: IF A LIFE, HEALTH AND ACCIDENT INSURER PROVIDES A CLAIM FORM FOR A
PERSON TO USE TO MAKE A CLAIM, THAT FORM MUST CONTAIN THE FOLLOWING STATEMENT OR A SUBSTANTIALLY
SIMILAR STATEMENT: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE
PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON."
RESIDENTS OF VIRGINIA 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 AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF WASHINGTON APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR
MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSES OF DEFRAUDING THE COMPANY.
PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.”
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Martial Arts School
Supplemental Application
Page 5 of 5
11/2009
RESIDENTS OF WEST VIRGINIA 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."
_______________________________________________________
Insured Signature Date
Title
_______________________________________________________
Producer Signature Date
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MARTIAL ARTS SCHOOL SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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