Martial Arts Studio General Liability and Property Application (Fitness and Wellness Insurance / Philadelphia Insurance Companies) (03/2011) Instructions

Check this box if there is an Accident/Medical policy in place but it provides no per-accident coverage (None). Fill only if 'Accident / Medical Policy in place — Yes' is 'Yes'.

Check this box if your Accident/Medical policy provides a per-accident limit of $5,000. Fill only if 'Accident / Medical Policy in place — Yes' is 'Yes'.

Check this box if your Accident/Medical policy provides a per-accident limit of $10,000. Fill only if 'Accident / Medical Policy in place — Yes' is 'Yes'.

Check this box if your Accident/Medical policy provides a per-accident limit of $25,000. Fill only if 'Accident / Medical Policy in place — Yes' is 'Yes'.

Check this box if your Accident/Medical policy provides a per-accident limit of $50,000. Fill only if 'Accident / Medical Policy in place — Yes' is 'Yes'.

Check this box if your Accident/Medical policy provides a per-accident limit of $100,000. Fill only if 'Accident / Medical Policy in place — Yes' is 'Yes'.

Check this box if your Accident/Medical policy provides a per-accident limit of $1,000,000. Fill only if 'Accident / Medical Policy in place — Yes' is 'Yes'.

Enter the full legal name of the brokerage or agency representing the account.

Enter the name of the broker, person in charge (PIC), or primary agency contact.

Enter the agency's street address, including number, street name and suite or unit if applicable.

Enter the city for the agency's mailing or physical address.

Enter the state for the agency's address (use the standard two‑letter abbreviation if applicable).

Enter the postal ZIP code for the agency address (5 digits or ZIP+4).

Enter the agency's primary phone number including area code and extension if needed.

Enter the agency's fax number including area code if available.

Enter the primary email address for the broker or agency contact.

Enter the number of years this location has been continuously in operation.

Provide the total gross revenue the business expects to receive in a 12‑month period.

Enter the total annual payroll paid by the business for all employees.

Enter the total usable floor area of the location in square feet.

Enter the current total number of active members or clients served by this location.

Enter the highest number of students you expect to be enrolled at the busiest time of the year.

Provide the typical monthly membership fee charged to members.

List the name(s) of the martial art(s) or fitness style(s) taught at this location; if more than one, separate with commas.

Enter the percentage of your total receipts that comes from operations not related to martial arts. Fill only if 'Business engages in operations not martial arts related — Yes' is 'Yes'.

Provide a brief explanation of the non-martial-arts operations, including the nature of the activities and any relevant details about those receipts. Fill only if 'Business engages in operations not martial arts related — Yes' is 'Yes'.

Check this box if there are NOT procedures in place to verify that individuals and parents carry their own health insurance. Fill only if 'Accident / Medical Policy in place — Yes' is 'Yes'.

Check this box if you do not have Accident/Medical coverage and you do want the insurer to provide a quote. Fill only if 'Accident / Medical Policy in place — No' is 'Yes'.

Check this box if the business is operated as a sole proprietorship (owned by a single individual).

Check this box if the business is organized as a partnership (owned by two or more partners).

Check this box if the business is organized as a corporation.

Check this box if the business is organized as a Limited Liability Company (LLC).

Check this box if the business is organized and taxed as an S Corporation.

Check this box if the business is a nonprofit organization.

If you have ever had a policy cancelled or non‑renewed, provide a clear explanation here including the carrier name, policy effective/expiration dates, reason for cancellation/non‑renewal, and any corrective actions taken or current status. Fill only if 'Have you been cancelled or non-renewed? — Yes' is 'Yes'.

Enter the retroactive date for the claims-made liability policy which indicates the earliest date for which prior acts are covered. Fill only if 'Current liability written on: Claims Made Basis' is 'Yes'.

Enter the date on which you want the insurance policy to become effective.

Check this box if the studio or insured holds the NAPMA certification (i.e., the applicable certification type for this application is NAPMA).

Check this box if the studio or insured holds the ACMA certification (i.e., the applicable certification type for this application is ACMA).

Check this box if the location is a private residence.

Check this box if the location is not a private residence.

Check this box if the location (when a private residence) has a separate entrance.

Check this box if the location (when a private residence) does not have a separate entrance.

Check this box if you have been cancelled or non-renewed by a prior insurance carrier.

Check this box if you have not been cancelled or non-renewed by a prior insurance carrier.

Check this box if the business DOES engage in operations that are not related to martial arts.

Check this box if the business DOES NOT engage in operations that are not related to martial arts.

Check this box if you carry Non-Owned and Hired Automobile Liability coverage.

Check this box if you do NOT carry Non-Owned and Hired Automobile Liability coverage.

Check this box if you need Stop Gap coverage for ND, WA, WY, or OH.

Check this box if you do NOT need Stop Gap coverage for ND, WA, WY, or OH.

Check this box if your current General or Professional Liability policy is written on an Occurrence basis.

Check this box if your current General or Professional Liability policy is written on a Claims-Made basis.

Check this box if there IS an Accident/Medical policy in place for the business.

Check this box if there is NO Accident/Medical policy in place for the business.

Check this box if you do NOT have Accident/Medical coverage and you WOULD like a quote for it. Fill only if 'Accident / Medical Policy in place — Yes' is 'Yes'.

Check this box if you do NOT have Accident/Medical coverage and you DO NOT need a quote for it. Fill only if 'Accident / Medical Policy in place — No' is 'Yes'.

Enter the belt rank or degree held by the owner or primary instructor (for example a number or brief text such as '1', '2nd Degree', or 'Black Belt').

Enter the full legal name of the business or entity as it appears on legal documents and tax records.

Enter the trade name or 'doing business as' name the business uses, or leave blank if there is no DBA.

Enter the full name of the individual or entity to be listed as the insured on the policy.

Enter the full name of the primary contact person for the business who can be contacted about this application.

Check this box if participants do not engage in any physical contact (no touching, grappling, sparring, or contact drills) during classes or activities.

Check this box if contact is minimal and incidental (brief, non‑forceful contact during instruction, adjustments, or controlled partner drills) but not full contact sparring.

Check this box if your program includes full physical contact such as sparring, grappling, or other forceful contact activities between participants.

Enter the total number of separate studio locations to be insured (use a numeral, e.g., 1).

Provide the full mailing/street address for correspondence, including suite, unit, or P.O. Box if applicable.

Enter the city of the mailing address.

Enter the state for the mailing address (use the two-letter abbreviation or full state name).

Provide the primary contact email address for the business or person completing this form.

Enter the postal ZIP or ZIP+4 code for the mailing address.

Enter the county in which the mailing address is located.

Provide the primary telephone number including area code and any extension if applicable.

Provide the fax number for the business, including the area code.

Enter the business website URL (include http:// or https:// if available).

Check this box to select a Medical Payments limit of $2,500.

Check this box to select a Medical Payments limit of $5,000.

Check this box to select an occurrence limit of $1,000,000 and an aggregate limit of $3,000,000 for General Liability coverage.

Check this box to select an occurrence limit of $2,000,000 and an aggregate limit of $3,000,000 for General Liability coverage.

Check this box to select an occurrence limit of $2,000,000 and an aggregate limit of $4,000,000 for General Liability coverage.

Check this box if you want an occurrence/aggregate limit not listed above and specify the alternative amounts in the provided 'Other' field or space.

Provide the alternate occurrence and aggregate liability limits for General Liability (the 'Other' option) as numeric amounts. Fill only if 'Occurrence/Aggregate Limit - Other' is 'Yes'.

Enter the full street address of the business location, including building number, street name and any suite or unit information.

Enter the city in which the physical address is located.

Enter the state for the physical address (use the two‑letter abbreviation or full state name).

Enter the postal ZIP code for the physical address, either five digits or ZIP+4 (e.g., 19104 or 19104-1234).

Enter the county where the physical address is located.

Enter the name of the previous insurance carrier for the Crime coverage in row 3.

Enter the expiration date of the previous Crime policy shown on row 3.

Enter the annual premium amount paid for the previous Crime policy in row 3 as a numeric value (include cents or thousands as needed).

Enter the name of the previous insurance company that provided the General Liability coverage for this location (prior carrier name).

Enter the expiration date of the prior General Liability policy (the date the previous policy ended).

Enter the annual premium amount paid to the previous General Liability carrier for this policy period.

Enter the name of the previous insurance carrier that provided property coverage for this location (row 1).

Enter the expiration date of the policy issued by the previous property carrier for this location (row 1).

Enter the annual premium amount paid to the previous property carrier for this policy (row 1).

Describe whether the location has a separate entrance and provide details (e.g., location of the entrance, access points, how it is used) to explain how the separate entrance functions. Fill only if 'Is the location a private residence? — Yes' is 'Yes'.

Check this box to select a tenant legal limit of $100,000.

Check this box to select a tenant legal limit of $200,000.

Check this box to select a tenant legal limit of $300,000.