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

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YOGA STUDIO GENERAL LIABILITY AND PROPERTY APPLICATION (Philadelphia Insurance Companies)

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YOGA STUDIO
GENERAL LIABILITY AND PROPERTY APPLICATION
SUBMISSION REQUIREMENTS
• Completed, signed, and dated PHLY Yoga 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 Resume if in business less than three (3) years
BROKER INFORMATION
Agency name:
Broker/PHLY 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: (Please complete a separate application for each location)
Check here if mailing address is the same as location address.
Mailing Address:
City: State: Zip: County:
Telephone Number: Fax:
E-mail
: Website:
Requested effective date:
Membership (Check membership if applicable)
Alternative Balance International Association of Reiki Professionals
Bones for Life Tai Chi for Health Community
North Ame
rican Studio Alliance Yoga Alliance
Bikram Tai Chi Chih - Joy Thru Movement
Ivengar Yoga National Association of the U.S. Universal Force International Naam Yoga Assocations
Kripalu Yoga Teachers Association Other:
Integral Yoga
Teachers Association Other:
International Association of Integrative Medicine
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Yoga Studio GL and Property Application
Page 1 of 8
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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PREVIOUS CARRIER INFORMATION
CARRIER EXPIRATION ANNUAL PREMIUM
Property $
General Liability
Crime
1. Have you been cancelled or non-renewed? If yes, explain. Yes No
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 yoga 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 numbe
r of Members/Clients:
7. Per se
ssion / monthly fee: $
Liability Coverages and Limits
Commercial General Liability/Professional Liability
Personal and Advertising Injury Liability
1. Occurrence / Aggregate Limit (please indicate):
$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:
$
$
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Yoga Studio GL and Property Application
Page 2 of 8
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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OPERATIONS
Employee and/or Independent Contractors:
1. Provide the number for each: Employees (part-time is less than 6 hours/week) and independent contractors.
Do not include the owner.
Staff
Independent Contractors
Full-time Part-time Full-time Part-time
Office Staff
Personal Trainers
Fitness Instructors
Yoga Instructors – Part-time < 6 hours
Physical Therapists
Massage Therapists
Pedicurist or Manicurists
Hair Stylists
Sports medicine professionals
Child Caregivers
Dieticians
Other:
TOTAL OF ABOVE:
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 Supplemental
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:
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
Yes No
Employees:
(Part-time is less than 6 hrs/wk)
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Yoga Studio GL and Property Application
Page 3 of 8
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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Trampolines: Ye
s No Number:
Rebounders only, all others excluded
Gymnastics: If yes, describe: Yes No
Exposures
1. 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
2. Are maintenance logs kept? Yes No
If no, are you willing to keep maintenance logs? Yes No
3. Please list who repairs exercise equipment:
3. Is signage used throughout facility to prevent injury? Yes No
4. Do you have non-slip surfaces in all wet areas? Yes No
5. Do you sub-lease to others? If yes, please explain: Yes No
6. Is there a retail shop? Yes No
7. Does the facility have a restaurant or snack bar/on-premises food preparation? Yes No
If yes, explain any type of cooking:
8. Do you serve liquor? If yes, please explain: Yes No
Do you charge a fee for liquor? Yes No
9. Are any products manufactured or sold under your label? Yes No
If yes, please describe the product and attach proof of manufacturer coverage:
10. Do you have a medical crisis plan? Yes No
11. Does the facility have medical facilities with doctors employed or contracted? Yes No
Please explain:
12. How many Automatic External Defibrillators (AEDs) do you have at each location:
How many employees at each location are trained to operate an AED:
Was full CPR training a part of the AED training? Yes No
13. Do you require health histories, intake questionnaires? Yes No
How long are they kept:
14. Off-premises events? If yes, please explain: Yes No
If yes, enter the number of events: Enter the number of participants:
15. Do you produce videos, books or other instructional media? Yes No
Number of videos, etc.:
Revenue from videos, etc.: $
16. What are your hours of operation:
Is staff present during all hours of operation? Yes No
Abuse and Molestation
1. Does Applicant’s employment application (for employees and volunteers) 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
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Yoga Studio GL and Property Application
Page 4 of 8
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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4. Does the Applicant conduct a personal in
terview? Yes No
5. Does Applicant have written procedures for dealing with sexual abuse? Yes No
If yes, attach a copy.
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 playgroun
d? Yes No
If yes, type of equipme
nt:
If outdoor, what type of surface is under the equipment:
What type of supervision is given to the playground:
Additional Insureds
Eligible Additional Insureds 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: Telephone Number:
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 followin
g:
Monthly Limitation: 1/3 1/4 1/6
(No coinsurance clause)
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Yoga Studio GL and Property Application
Page 5 of 8
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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REQUIRED UNDERWRITI
NG 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 PHLY 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
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Yoga Studio GL and Property Application
Page 6 of 8
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and
belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application)
are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application
changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or
withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
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 AND SUBJECTS THAT PERSON
TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH
MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND
DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA,
ME, MD, MN, NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN
AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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.
APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, 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, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC
COMMUNICATION OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN
INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN
INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE 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.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSONS FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE
OF MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, 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. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE
CLAIM FOR EACH SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
_____________________________________________________________
SIGNATURE DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
Yoga Studio GL and Property Application
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10/2017
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PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
The insurer may not be subject to all insurance laws and regulations 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
Yoga Studio GL and Property Application
Page 8 of 8
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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