Fillable MARTIAL ARTS STUDIO GENERAL LIABILITY AND PROPERTY APPLICATION (Philadelphia Insurance Companies)

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MARTIAL ARTS STUDIO GENERAL LIABILITY AND PROPERTY APPLICATION (Philadelphia Insurance Companies)

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Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Martial Arts Studio GL and Property Application Page 1 of 8
03/2011
MARTIAL ARTS STUDIO
GENERAL LIABILITY AND PROPERTY APPLICATION
SUBMISSION REQUIREMENTS
• Completed, signed, and dated PHLY Martial Arts Studio Supplemental application
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years. If none,
a No Loss Letter is required.
• Website information
• Copy of your Hold Harmless Agreement and Sparring Rules
• Copy of Resume if in business less than three (3) years
BROKER INFORMATION
Agency name:
Broker/PIC Rep/Contact:
Address:
City: State: Zip Code:
Phone: Fax: E-mail:
GENERAL INFORMATION
Legal Business Name:
Doing business as (DBA):
Insured’s Name:
Contact Name:
Business Entity: Sole Proprietorship Corporation LLC
Partnership S Corporation Non-Profit
Physical Address:
City: State: Zip: County:
Is the location a private residence? Yes No
If yes, is there a separate entrance? Please explain: Yes No
Number of Locations: (Complete a separate application for each location)
Check here if mailing address is the same as location address.
Mailing Address:
City: State: Zip
: County:
Teleph
one Number: Fax:
E-mail: Website:
Requested effective date:
Certification Type: NAPMA ACMA
PREVIOUS CARRIER INFORMATION
CARRIER EXPIRATION ANNUAL PREMIUM
Property $
General Liability $
Crime $
1. Have you been cancelled or non-renewed? If yes, explain. Yes No
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Martial Arts Studio GL and Property Application Page 2 of 8
03/2011
GENERAL LIABILITY*
Multiple locations must complete a separate application for each location
*General Liability coverage is written through the Fitness & Wellness Risk Purchasing Group. A Fee is required to join this Risk
Purchasing Group. This fee may vary, but the exact amount will be indicated on your proposal and / or invoice.
1. Does business engage in operations not martial arts related? Yes No
If yes, explain and indicate the % of your receipts this represents: %
2. Years in Business:
3. Gross Annual Revenues: $
4. Gross Payroll:$
5. Square Footage:
6. Total number of active Members/Clients:
7. Projected maximum number of students you have enrolled at your busiest time of year:
8. Monthly Membership Dues: $
9. Name of Art/Style you teach (if more than one, please list all styles taught):
10. Level of contact: None Light Full
11. Belt rank of owner or primary instructor:
Liability Coverages and Limits
Commercial General Liability/Professional Liability
Personal and Advertising Injury Liability
1. Occurrence / Aggregate Limit (please indicate):
$1,000,000 / $3,000,000
$2,000,000 / $3,000,000
$2,000,000 / $4,000,000
Other:
2. Sexual Abuse Liability $100,000 per occurrence / $300,000 aggregate
3. Tenant Legal Limit (please indicate):
$100,000
$200,000
$300,000
4. Medical Payments (please indicate):
$2,500
$5,000
5. Non-Owned and Hired Automobile Liability Yes No
6. Stop Gap (ND, WA, WY, OH) Yes No
7. Is your current General Liability or Professional Liability written on an:
Occurrence Basis Claims Made Basis
If claims made, what is the retroactive date:
Is there an Accident / Medical Policy in place? Yes No
If yes, what limits are carried (Per Accident)?
None $10,000 $50,000 $1,000,000
$5,000 $25,00
0 $100,000
Are there procedures in place to verify that individuals and parent carry their own
health insurance?
Yes
No
If you do not have Accident / Medical Coverage, do you need a quote? Yes No
8.
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Martial Arts Studio GL and Property Application Page 3 of 8
03/2011
OPERATIONS
Exposures and Equipment
Equipment
1. Please enter in the total pieces of equipment at this location:
Do not count free weights, steps, mats, bands, and balls:
Please specify “Yes” or “No” and the quantity for each equipment type
listed below:
Jacuzzis: Yes No Number:
Steam Rooms: Yes No Number:
Saunas: Yes No Number:
Courts or Tracks: Yes No Number:
Climbing Walls Indoor: Yes No Number:
Climbing Walls Outdoor: Yes No Number:
If yes to climbing walls, a climbing wall supplement is necessary.
Swimming Pools: Yes No Number:
Are all swimming pools and spas compliant with the Virginia Graeme Baker Pool and
Safety Act? If no, provide a time table and action plan:
Yes
No
Diving Boards: Yes No
If yes, what is the height:
Tanning Beds/Booths: Yes No
If yes, how many:
If yes:
Are goggles required? Yes No
Are token timers used? Yes No
Are operators present? Yes No
Are controls on the outside of the booth/bed? Yes No
Are tanning booth waivers signed by members? Yes No
Are only the manufacturer suggested bulbs used? Yes No
Type of bulbs used: UVA %: UVB %:
Are warning signs posted regarding ultraviolet rays? Yes No
Boxing Rings: Yes No Number:
If yes, is it Cardio-Kickboxing only? Yes No
Trampolines: Yes No Number:
Rebounders only, all others excluded
Gymnastics: Yes No
If yes, describe:
Exposures
1. Are kicking motions to head permitted in sparring? Yes No
If yes, explain:
Is there free sparring? Yes No
If yes, is it: Light Contact Full Contact None (Cardio Only)
2. Do you have conventional boxing? Yes No
If yes, is it: Light contact Full contact None (Cardio Only)
3. Do you offer kickboxing? Yes No
If yes, is it Light contact Full contact None (Cardio Only)
4. Do you participate in tournaments? Yes No
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Martial Arts Studio GL and Property Application Page 4 of 8
03/2011
5. Do you sponsor tournaments? Yes No
If yes, provide number of participants and number of
tournaments per year:
6. Do you have weapons training (only padded weapons
eligible)? If yes, explain:
Yes
No
7. Describe any other services/operations not listed/described above:
8. Do you require signed waivers from all clients? Yes No
If no, are you willing to require signed waivers by the effective date of this policy? Yes No
9. Are maintenance logs kept? Yes No
If no, are you willing to keep maintenance logs? Yes No
10. Please list who repairs exercise equipment:
11. Is signage used throughout facility to prevent injury? Yes No
12. Do you have non-slip surfaces in all wet areas? Yes No
13. Do you sub-lease to others? If yes, please explain: Yes No
14. Is there a retail shop? Yes No
15. Does the facility have a restaurant or snack bar/on-premises food preparation? Yes No
If yes, explain including any type of cooking:
16. Do you serve liquor? If yes, please explain: Yes No
Do you charge a fee for liquor? Yes No
17. Are any products manufactured or sold under your label? Yes No
If yes, please describe the product and attach proof of manufacturer coverage:
18. Do you have a medical crisis plan? Yes No
19. Does the facility have medical facilities with Doctors employed or contracted? Yes No
Please explain:
20. Do you require health histories, intake questionnaires? Yes No
How long are they kept?
21. Off-premises events? If yes, please explain: Yes No
If yes, enter the number of events: Enter the number of participants:
22. Do you produce videos, books or other instructional media? Yes No
Number of videos, etc.: Revenue from videos, etc.: $
Abuse and Molestation
1. Does Applicant’s staff (paid & volunteer) employment application include questions about
whether the individual has ever been convicted for any crime, including sex-related or
child-abuse related offenses?
Yes
No
2. Does Applicant’s state permit you to do criminal background investigations? Yes No
If yes, does the Applicant routinely request and receive such background investigations? Yes No
3. Does the Applicant verify employment-related references? Yes No
4. Does the Applicant conduct a personal interview? Yes No
5. Does Applicant have written procedures for dealing with sexual abuse? Yes No
If yes, attach a copy.
Participants: Tournaments:
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Martial Arts Studio GL and Property Application Page 5 of 8
03/2011
6. Do you have a plan of supervision that monitors staff in day-to-day relationships with
clients, both on and off premises?
Yes
No
7. Has Applicant ever had an incident which resulted in an allegation of sexual abuse? Yes No
If yes, describe:
Day Nursery/Babysitting
1. Are waivers signed by parents? Yes No
2. Ratio of staff to children:
3. Qualifications of staff:
4. Activities occurring:
Is there a playground? Yes No
If yes, type of equipment:
If outdoor, what type of surface is under the equipment:
What type of supervision is given to the playground:
Additional Insureds
Eligible Additional Insured criteria include landlords, property managers, equipment rental companies, mortgagees
and lien holders. Please contact customer service if you have a different type of entity. If you are hosting a special
event, tournament, retreat or any other type of off-site event please contact customer service for a quote at 877-438-
7459.
Name: Type of Insured:
Address:
City: State: Zip Code:
E-Mail: Phone:
PROPERTY SECTION
Check this box if you DO NOT WANT property coverage and proceed to signature page.
Multiple locations must complete a separate application for each location.
Property coverage cannot be purchased on stand-alone basis.
Building(s)
Loc. No. Bldg. No. ACV/RC Limit of Insurance Coinsurance
$ 90%
Contents
Loc. No. Bldg. No. ACV/RC Limit of Insurance Coinsurance
$ 90%
Tenant Improvements and Betterments
Loc. No. Bldg. No. ACV/RC Limit of Insurance Coinsurance
$ 90%
Deductible $500 $1,000 Other: $
Business Income
Loc. No. Bldg. No. ALS Limit of Insurance Coinsurance
$ 50%
Monthly Limit of Indemnity Form also available. If desired, please indicate the following:
Monthly Limitation: 1/3 1/4 1/6
(No coinsurance clause)
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Martial Arts Studio GL and Property Application Page 6 of 8
03/2011
REQUIRED UNDERWRITING INFORMATION
1. Construction of Building Number of Stories:
Walls: Wood Frame Brick / Brick Steel Frame Other:
Roof: Wood Frame Poured Concrete Steel Frame Other:
Floor: Wood Frame Concrete Other:
2. Year Built: Square Footage: Age of Roof:
If building is over 25 years old, provide year of update for:
Roof: Wiring: Plumbing: Heating:
3. Burglar Alarm: Yes No
If yes, Central Station with Keys Central Station without Keys
Fire Alarm Yes No If yes, Central Station Local Gong
4. Does the property have automatic fire sprinklers? Yes No
5. Distance from building to: Fire Hydrant (feet): Fire Station (miles):
6. Does the property have aluminum wiring? Yes No
If yes, has it been retrofitted with one of the PIC approved connectors and by a licensed
electrician?
Yes
No
Indicate which one:
COPALUM Yes No
AlumiConn Yes No
Date updated:
Please supply retro-fit documentation or statement from installing contractor.
7. Does the Applicant own the building? Yes No
If no, who does?
8. Mortgagee:
9. Loss Payee:
10. Signs
Type
Value Location
1. $
2. $
3. $
Flood
11. Does the Applicant have a current flood policy in force? Yes No
If yes, attach a copy of the declarations page.
If no, would you like a flood quote with our proposal? Yes No
(Flood quote will be secured through the Write Your Own Flood Program)
Crime
12. Theft, Disappearance and Destruction: $
13. Loss Inside the Premises: $
Loss Outside the Premises: $
14. Employee Dishonesty: $
15. Number of officers and employees who have custody of the money:
16. By whom is financial audit completed:
17. Frequency of audits:
18. Is there a countersignature procedure in place? Yes No
19. Frequency of bank deposits:
20. Are accounts reconciled by someone not authorized to deposit or withdraw monies? Yes No
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Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Martial Arts Studio GL and Property Application
03/2011
Page 7 of 8
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.”
RESIDENTS OF ALASKA 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.”
RESIDENTS OF ARKANSAS 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.”
RESIDENTS OF ARIZONA 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."
RESIDENTS OF COLORADO 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.”
RESIDENTS OF 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.”
RESIDENTS OF 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.”
RESIDENTS OF KANSAS APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON CAUSES TO BE PRESENTED 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 STATEMENT AS
PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY, OR A CLAIM
FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY WHICH SUCH PERSON KNOWS TO CONTAIN
MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO, 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.”
RESIDENTS OF 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.”
RESIDENTS OF 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 SUBJECT TO FINES AND CONFINEMENT IN PRISON.”
RESIDENTS OF 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.”
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 O
F MINNESOTA APPL
ICANTS: “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.”
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03/2011
Page 8 of 8
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 VERMONT APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICTION
FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.”
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.”
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."
The insurer may not be subject to all insurance laws and regulation of this state. The member benefits
described are guaranteed through an insurance contract. The Fitness and Wellness Risk Purchasing
Group’s Insurance policy is underwritten by Philadelphia Indemnity Insurance Company
Note: the Insurer may not be subject to all of the insurance laws and regulations of your resident st
ate.
___________________________________________________
Signature Date
Title
Producer Signature Date
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MARTIAL ARTS STUDIO GENERAL LIABILITY AND PROPERTY APPLICATION (Philadelphia Insurance Companies)

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