STSA 11/10
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IV. ELIGIBILITY CRITERIA
1. No bankruptcies, tax or credit liens against the applicant in the last five years q True q False
2. Coverage has not been cancelled or non-renewed in the last three years (not applicable in Missouri) q True q False
If False, advise reason ___________________________________________________________________________________________________
3. Insured does not occupy more than 25,000 square feet q True q False
4. No armed security on premises at any time q True q False
5. For any building built prior to 1978, 100% of the electric wiring is on functioning and operating
circuit breakers q N/A q True q False
6. For any building built prior to 1978, there is no aluminum wiring or knob and tube wiring q N/A q True q False
7. Functioning and operational smoke and/or heat detectors in all units and/or occupancies q True q False
General Liability
1. Background and criminal checks completed on all staff q True q False
2. No more than $3,000,000 in annual gross receipts q True q False
3. No swimming pools q True q False
4. No on-water activity or instruction q True q False
5. No archery or firearms activities or training q True q False
6. No cheerleading or gymnastic activities, equipment or instruction q True q False
7. No karate, martial arts or similar type activity or instruction q True q False
Art & Craft/Hobby Instruction
1. Kilns are UL approved q True q False
2. Proper storage of all paints and flammables in metal file cabinets q True q False
3. No glassblowing operations q True q False
Athletic Instruction, Dance Instruction and Personal Trainers
1. All participants/guardians must sign a waiver of liability/release of liability as a condition of participation q True q False
2. No professional athlete training q True q False
Cooking
1. Commercial cooking protected by extinguishing system meeting NFPA #96 standards q True q False
2. Annually serviced fire extinguishers mounted by cooking equipment q True q False
Medical/Nursing
1. No lab or clinical training; contemplates classroom training only q True q False
2. No CPR or first aid schools or instructors q True q False
3. No childbirth or parenting classes q True q False
V. ADDITIONAL APPLICANT INFORMATION
Form of business: q Individual q Corporation q Partnership q LLC q Other: ___________________________
Applicant’s mailing address: _____________________________________ (if different than the location address above)
City: ______________________________________________________ State: ______________________ Zip code: ___________________
E-mail address of primary contact: _____________________________________________ Phone: ____________________________________
Inspection contact name: _______________________________________ Telephone/E-mail address: ___________________________________
Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of
the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment
of premium.”
Colorado Fraud Statement: 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.
District of Columbia Fraud Statement: 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.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted
