Exercise And Health Studio Supplemental Application Page 2
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27. Please indicate any of the following that you provide to your customers:
θ Protein diet plans
θ Body wraps—other than organic
θ Blood analysis
θ Stress testing
θ Weight loss or diet clinics
θ Products manufactured by or sold under club’s name
8. Premises exposures:
Hours of operation from
to
________________
________________
Is parking lot well lit? ............................................................................................................................... ο Yes ο No
Security Guard on premises? .................................................................................................................. ο Yes ο No
Shower/sauna/steam or Jacuzzi facilities?............................................................................................... ο Yes ο No
Do the floors for these areas have non-skid surfaces?............................................................................. ο Yes ο No
Any trampolines? .................................................................................................................................... ο Yes ο No
Any electrode machines? ........................................................................................................................ ο Yes ο No
9.
Number of Employees
Employed
Leased
Independent
Certified aerobic instructors
Uncertified aerobic instructors
Personal trainers
Masseuses
Other (describe)
Total number of employees
Number of employees trained in CPR
Do independents provide you with certificates of insurance? ................................................................... ο Yes ο No
Are you included as an additional insured?.............................................................................................. ο Yes ο No
APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information, or conceals for the purpose of misleading, in-
formation concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
FRAUD WARNING:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
PRODUCER’S SIGNATURE:
____________________________________________________________________
DATE:
___________________________________
_____________________________________________________________________
___________________________________
APPLICANT’S SIGNATURE:
DATE:
AGENT NAME:
____________________________________________________________
AGENT LICENSE NUMBER:
___________________________
(Applicable to Florida Agents Only.)
Page 2 of 2
GLS-APP-20s (3-02)
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