Fitness Class Studio Form - Dance Studio Insurance

Policyholder Details

Full Legal Name of Policyholder (required)*

This is the legal name of your business, school or studio.

Contact Person (required)*

First Last

Phone (required)*

Email (required)*

Website

Fax

Mailing 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 ZIP Code

What types of classes are taught? Please be specific. (required)*

List all the class offerings (i.e. Hatha Yoga, Power Yoga, Hot Yoga, mat Pilates, spinning, aerobics, Zumba, etc.) NOTE: Martial Arts, MMA training, Boxing (other than Cardio Kickboxing), sports training and healthclub facilities are NOT eligible under this program.

Does the studio offer any aerial activities?*

Yes
No

Please provide a description of the aerial equipment used at the studio:

What is the maximum height someone is in the equipment, off the ground?

Does your studio offer or provide any of the following: tanning beds, spa/massage, sauna, sports medicine or physical therapy, professional athlete training, daycare facilities, 24 hour access, unsupervised and/or keyed access? (required)*

If your answer is Yes, please visit the HEALTH CLUB application (Click on "Health Clubs: Tab at the top of the page)

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 ZIP Code

Physical Address 2

Street Address Address Line 2 City State 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 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).

Has your past liability coverage been cancelled in any way in the last three years? (required)*

Yes
No

Please be specific:

Risk Management Plan

Do you currently have a risk management plan? (required)*

Risk Management is a method for identifying risks and developing and implementing programs to first, prevent or reduce accidents, injuries or loss and second, to protect the organization. You have agreed to have a Risk Management Plan in place during the coverage period of your policy. If you do not yet have such a plan in place, click here for our Guide to Risk Management.

Yes

Waiver Requirement

Do 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)*

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)*

Please Select the General Aggregate Limit: (required)*

Please Select the General Aggregate Limit (required)*

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:

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:

Add $5,000 Medical Expense Benefit for $10.00

This 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 $10.00

This 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 $10.00

This 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 Benefit

Additional Optional Coverage(s) **: (Please check any that you would like additional information and/or quotes.)

Equipment Coverage

Up to $750,000.00 - This Inland Marine insurance product provides coverage for your equipment and contents up to the specified limit. If you select this option, please also submit the Equipment Floater Application which will open in a new browser window.

Plan 1 Attendee Calculation -

Plan 1 Attendee Calculation

Plan 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 - A

Plan 2 Attendee Calculation

Plan 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 Calculation

Plan 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 Calculation

Plan 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 Calculation

Plan 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 Insured

Standard 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 Name

Address

Street Address City State ZIP Code

Relationship

Additional Insured 2 Name

Address

Street Address City State ZIP Code

Relationship

Additional Information

How 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 Policy

Please read the statement below: (required)*

Fitness Studio

Policyholder Details

Risk Management Plan

Waiver Requirement

Premium Calculation

Additional Insured

Additional Information

Cancellation / Refund Policy

Terms & Conditions

Payment Options

Administration Fee

Total Premium Due Today

Please enter payment information below

Payment Billing Address