HEALTH & EXERCISE CLUBS & TANNING SALONS APPLICATION

Applicant's Name:
Mailing Address:
City    State        Zip
Phone:      Fax:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:

 1. Individual    Partnership    Corporation     Other (Explain) 
 2. Date Established

 3. Address of Location to be insured (If same as Mailing Address, note) and Additional Locations:
   

 4. Has applicant had previous insurance for this enterprise? Yes   No
    If Yes, Provide the following information:

Insurance Company
Policy Period
Limits of Liability
Premium
Occurrence or Claims Made
Type of Coverage

 5. Is applicant engaged in, owned by, associated with or involved in any other enterprise? Yes   No
 6. Provide details of licensing or certification needed for this operation:   

 7. Provide the number of the following personnel
   Partners, Owners, Officers Part Time Staff Other
   Full Time Staff Independent Contractors Other

 8. During the past (3) three years, have any claims been presented to your current or prior insurance carrier? Yes   No
     If yes, give full details...include description of claim, amounts paid and reserves
     

 9. Is the applicant, or any other person for whom insurance is being requested, aware of any circumstance which may result in a
     claim? Yes   No
      If yes, provide full details:   

 10. Has applicant, or any other person for whom coverage is being requested had any liability application denied, policy cancelled
       or policy not renewed in past (3) three years?   Yes   No
      If yes, provide full details:   

 11. Please check for facilities available:
      Tanning Beds/Booths (Forward copy of Client Questionnaire)      $ Receipts
              Bulbs: UVA      UVB        Mfg. by:     Protective Covering? Yes      No
              No. Beds/Booths      Mfg by, Installed by:
              Goggles worn? Yes      No      Location of timers
              Have all employees received training in the use of timers? Yes      No

       Pool           Diving Board (Depth at deepest end)             FT. Depth Markers Yes      No
              Is there a lifeguard on duty?      Yes      No

       Whirlpool       Aerobics       Free Weights       Nautilus/Universal or similar weight machines

       Sauna/Steam Room       Racquetball/Tennis/Handball Court       Nutritional Counseling

       Jogging Track       Snack/Juice Bar, Restaurant (Type of food served?)

 12. Do showers, pool and whirlpool area and steam room have non-skid floors? Yes      No

 13. Do you provide facilities for child care for your clients?    Yes      No
       If yes, please complete the following:
       (a) Number of children cared for at any one time    #
       (b) Number of child care attendants    #
       (c) Age of youngest you will accept   Age

 14. Total number of members:

 15. Average age of members?

 16. Are medical examinations required for new members?    Yes      No

 17. What is your procedure for handling accidents or injuries?

 18. Does your staff have training in CPR and First Aid?   Yes      No

 19. List and products sold on premises:

 20. Hours of operation:  From   To

 21. Annual Receipts: $

 22. Name and Phone Number of person to contact for audit:
       Name      Phone

 Remarks:   

 Application Completed By:     Date: