Policyholder DetailsFull Legal Name of Policyholder (required)*This is the legal name of your business, school or studio.Type of Operation* Corporation Individual/Sole Prprietor Partnership/Joint Venture Limited Liability LLC Non Profit Other Contact Person (required)* First Last Phone (required)*Email (required)* WebsiteFaxMailing Address (required)*This will be the address listed on the policy. If the physical location of the studio is different from the mailing address, you will able to enter in the physical location(s) below. Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Policy Start Date:*All policies are issued on an annual term. The policy can start the date payment is received or any future date (within 6 months). MM slash DD slash YYYY General Liability QuestionaireHas your past liability coverage been canceled in any way in the last three years?* Yes No Does your organization currently utilize a waiver system?* Yes No Does your organization currently have a risk management plan?A Risk Management Plan is a document that identifies potential risks for your organization and defines a set of procedures that all involved individuals should follow to avoid or reduce those risks. A Risk Management Plan may be called a safety plan or emergency procedures. Yes No Is your current insurer non-renewing coverage?* Yes No Have any liability claims been paid by your insurer during the last three years?* Yes No Does your organization have a formal safety training program for employees?* Yes No Does your organization have surveillance cameras?* Yes No Does your organization have a central station fire and burglar alarm?* Yes No Does your organization include an air supported structure and/or dome? Yes No Are incident reports completed and maintained for all injuries, regardless or severity?* First Choice No Does your organization have playground equipment? Yes No Please enter your organization's Annual Gross Receipt (USD):*What kind of classes do you offer?* Aerobics Barre Boot Camp Bungee Fitness Cardio Boxing Cardio Kickboxing Circuit Training CrossCore Indoor Cycling High Intensity Interval Training Jump Rope Pilates Spinning Stretching Strength Training Tai Chi Yoga Weights Zumba Other not listed above If Other was selected, please describe below:*Does your organization provide onsite child care services during fitness classes?* Yes No Does your organization operate tanning bed(s)?* Yes No Does your organization provide spa or massage services?* Yes No Is there a sauna on premises? Yes No Does your organization provide sports medicine?* Yes No Does your organization provide physical or occupational therapy?* Yes No Does your organization provide professional athlete training?* Yes No Does your organization operate licensed daycare facilities (not child care services for participants during classes)?* Yes No Does your organization operate any 24 hour facilities with unsupervised or keyed access?* Yes No Is the mailing address the same as your studio location (i.e. physical address)? (required)* Yes No Physical Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Physical Address 2 Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you have multiple locations? (required)*Please note that all covered locations must be covered under the same Tax ID / Business Entity Yes No Physical Address 3 Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Has your past liability coverage been cancelled in any way in the last three years? (required)* Yes No Please be specific:Risk Management PlanWaiver RequirementDo you agree to use a waiver or have a waiver and release system in place at the time coverage is bound? (required)*Each school or studio must implement a Release and Waiver of Liability and Indemnity Agreement for all students and staff members. Unintentional error on your part in securing Waiver and Release forms shall not void your coverage in the event of an occurrence to a student or staff member. However, your failure to maintain an adequate system to regularly secure Waiver and Release forms shall void your coverage in the event of an occurrence to a student or staff member. If No, click here to download a waiver. Yes Premium Calculation*All policies are issued with a $1,000,000.00 occurrence limit and include a $100,000 Accident Policy *Premiums are based on the number Participants in the busiest month of the year *Minimum Premium Applies. *Please provide your best estimate at time of application Please select your State (required)*AlabamaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming(Select)Total Number Participants in the Busiest Month of the Year*Please provide the best estimate, counting each participant only once. So if someone comes 3x per week, you would only account for them 1 time.Please Select the General Aggregate Limit: (required)* Plan 1 ($1 Million) Plan 2 ($2 Million) Plan 3 ($3 Million) Plan 4 ($4 Million) Plan 5 ($5 Million) Please Select the General Aggregate Limit (required)* Plan 1 ($1 Million) Plan 2 ($2 Million) Plan 3 ($3 Million) Plan 4 ($4 Million) Plan 5 ($5 Million) Subtotal Policy Premium:Minimum Premium for Plan Selected (total premium due calculated below)Subtotal Policy Premium:Minimum Premium for Plan Selected (total premium due calculated below)Subtotal Policy Premium:Minimum Premium for Plan Selected (total premium due calculated below)Optional Coverage(s)Add Optional Hired and non-owned automobile liability coverage?This liability coverage provides protection for rented, borrowed and other non-owned vehicles driven on studio business No $150,000 Limit ($225 premium) $500,000 Limit ($500 premium) $1,000,000 Limit ($850 premium and our receipt and approval of our Hired/Non-owned Auto supplemental application. Please contact me if you would like this application.) Add Optional Hired and non-owned automobile liability coverage?This liability coverage provides protection for rented, borrowed and other non-owned vehicles driven on studio business No $150,000 Limit ($225 premium) $500,000 Limit ($500 premium) $1,000,000 Limit ($850 premium and our receipt and approval of our Hired/Non-owned Auto supplemental application. Please contact me if you would like this application.) Add Optional Hired and non-owned automobile liability coverage?This liability coverage provides protection for rented, borrowed and other non-owned vehicles driven on studio business No $150,000 Limit ($225 premium) $500,000 Limit ($500 premium) $1,000,000 Limit ($850 premium and our receipt and approval of our Hired/Non-owned Auto supplemental application. Please contact me if you would like this application.) Optional Auto Coverage:Optional Auto Coverage:Optional Auto Coverage:Add $100,000 Sexual Abuse & Molestation Liability coverage?Liability coverage is provided for claims arising out of alleged sexual abuse and/or molestation. No Yes $1,000 premium Add $100,000 Sexual Abuse & Molestation Liability coverage?Liability coverage is provided for claims arising out of alleged sexual abuse and/or molestation. No Yes $1,000 premium Add $100,000 Sexual Abuse & Molestation Liability coverage?Liability coverage is provided for claims arising out of alleged sexual abuse and/or molestation. No Yes $1,000 premium Optional Abuse/Molestation Coverage:Optional Abuse/Molestation Coverage:Optional Abuse/Molestation Coverage:Add $5,000 Medical Expense Benefit for $10.00This coverage will reimburse an injured spectator or guest for medical and/or funeral expenses incurred as a result of bodily injury or death, regardless of whether you are liable or not. (This is for spectators/Guests ONLY. Participants are covered for medical expenses under the Accident Policy) No Yes, add this to my policy ($10 premium) Add $5,000 Medical Expense Benefit for $10.00This coverage will reimburse an injured spectator or guest for medical and/or funeral expenses incurred as a result of bodily injury or death, regardless of whether you are liable or not. (This is for spectators/Guests ONLY. Participants are covered for medical expenses under the Accident Policy) No Yes, add this to my policy ($10 premium) Add $5,000 Medical Expense Benefit for $10.00This coverage will reimburse an injured spectator or guest for medical and/or funeral expenses incurred as a result of bodily injury or death, regardless of whether you are liable or not. (This is for spectators/Guests ONLY. Participants are covered for medical expenses under the Accident Policy) No Yes, add this to my policy ($10 premium) Optional Medical Expense BenefitOptional Medical Expense BenefitOptional Medical Expense BenefitAdditional Optional Coverage(s) **: (Please check any that you would like additional information and/or quotes.)Equipment CoverageTo request coverage for the studio's contents and equipment, select Yes, and we will email you an application to get a quote to the email above. This Inland Marine insurance product provides coverage for your equipment and contents up to the specified limits. This field is hidden when viewing the formPlan 1 Attendee Calculation -This field is hidden when viewing the formPlan 1 Attendee CalculationPlan 1 Attendee CalculationPlan 1 Attendee Adjustment Calculation Price: $0.00 Plan 1 Attendee Adjustment Calculation Price: $0.00 Plan 1 Attendee Adjustment Calculation Price: $0.00 Plan 2 Attendee Calculation - APlan 2 Attendee CalculationPlan 2 Attendee CalculationPlan 2 Attendee Adjustment Calculation Price: $0.00 Plan 2 Attendee Adjustment Calculation Price: $0.00 Plan 2 Attendee Adjustment Calculation Price: $0.00 Plan 3 Attendee CalculationPlan 3 Attendee CalculationPlan 3 Attendee CalculationPlan 3 Attendee Adjustment Calculation Price: $0.00 Plan 3 Attendee Adjustment Calculation Price: $0.00 Plan 3 Attendee Adjustment Calculation Price: $0.00 Plan 4 Attendee CalculationPlan 4 Attendee CalculationPlan 4 Attendee CalculationPlan 4 Attendee Adjustment Calculation Price: $0.00 Plan 4 Attendee Adjustment Calculation Price: $0.00 Plan 4 Attendee Adjustment Calculation Price: $0.00 Plan 5 Attendee CalculationPlan 5 Attendee CalculationPlan 5 Attendee CalculationPlan 5 Attendee Adjustment Calculation Price: $0.00 Plan 5 Attendee Adjustment Calculation Price: $0.00 Plan 5 Attendee Adjustment Calculation Price: $0.00 Total Policy Price:Total Policy Premium Due Today: $0.00 Additional InsuredStandard Additional insureds (not including independent contractors) are included at no additional cost. Additional Insureds can include Landlords, Venues, Event Operators, Franchisor/Franchise Owner, and Govermental Agencies. If the relationship of the additional insured is not listed above, please submit their relationship for prior approval. Additional Insured 1 NameAddress Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code RelationshipAdditional Insured 2 NameAddress Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code RelationshipAdditional InformationHow did you hear about us? (required)*Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not in force until accepted by Anthony Insurance Services, Inc. Coverage is subject to the receipt of payment of the required premium by Anthony Insurance Services, Inc. Coverage will begin on the date of acceptance or on the date requested, whichever is later.I, the applicant, declare, to the best of my knowledge and belief, that all statements and answers in this application are true and complete. I understand and agree that (a) this application will form part of any policy issued, (b) no information given to or acquired by any representative of the Company will bind it, unless it is in writing on this application, (c) no waiver or modification will bind the Company unless it is in writing and is signed by an executive officer of the Company, and (d) only those persons eligible under the terms of an issued policy will be insured.Authorized Electronic Signature:*Title or Position:Cancellation / Refund PolicyPlease read the statement below: (required)* If I cancel the policy at any time during the policy term, I understand that all minimum premiums are FULLY earned, and will not be refunded. If my policy was issued above minimum premium, a pro-rated premium refund will be issued based on the date of cancellation. By checking this box, I understand the cancellation / refund policy Terms & ConditionsTerms & ConditionsI have read and agree with the Terms & Conditions. Yes Payment OptionsPayment (required)* I do not wish to purchase coverage today. I would like to receive follow-up from Anthony Insurance Services, Inc. Please charge my credit card for the Total Policy Premium Due Today plus the administration fee of $20.00. Administration FeeAdministration Fee AmountA $20 administration fee is added to all policy premium payments. Price: Total Premium Due TodayTotal Due Today $0.00 Please enter payment information belowCredit Card (required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Payment Billing AddressBilling Address*The billing address will be the same address that the card issuing bank has on file for the credit/debit card you are using for this transaction. Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice
