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Preferred Effective Date?

MM slash DD slash YYYY

Location(s) Information

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Is the current carrier non-renewing coverage?*

Yes

Does management have 3 years' experience?*

Yes

Have you had more than $5,000 of total claims in the last 3 years?*

Yes

This is the total of any General Liability and/or Accident Medical claims you have had within the past three years, including any amounts paid to investigate and/or settle the claim.

If so, explain*

Do you host or participate in any tournaments or competitions?*

Yes

This program does not provide coverage for competitions or tournaments involving the following styles or disciplines: Muay Thai-Thai Boxing, Kali, Escrima, Savate, Sayoc kali, Dim mak, Haganah and full contact and submission mixed martial arts, including but not limited to cage events, extreme fighting and ultimate fighting.*

Accept and continue

Decline and exit

Do you have activities that occur away from the facility/premises other than competitions, demonstrations, parades or fundraising activities?*

Yes

Please select the style(s) of martial arts taught in your facility (select all that apply):*

Akido

Brazilian Jiu Jitsu

Capoeira

Chi Kun

Dim mak (instruction only)

Fitness Boxing (non-contact)

Goju-ryu

Haganah (instruction only)

Hapkido

Jeet kune do

Judo

Jiu Jitsu

Kali/escrima (instruction only)

Karate

Kenjitsu

Kickboxing (cardio/fitness only)

Krav Maga

Kung Fu

Mixed martial arts (Ultimate/extreme/cage fighting) (instruction only)

Savate (instruction only)

Sayoc kali (instruction only)

Shaolinquan

Taekwondo

Tai Chi

Taijiquan

Tang soo do

Thai boxing/muay thai (instruction only)

Wushu

Does your facility include any of the below activities?

Yes

• Acrobatic and/or circus silk training • Boxing (contact/sparring) • Cage Fighting • Cheerleading • Climbing Walls • Dim mak • Gymnastics Training • Kali/Escrima • Muay Thai • Ultimate Fighting/UFC • Parkour/Free Running • Trampolines • Trapezes • Zip Lines

If so, which ones?*

Untitled Do you have any programs involving parkour, urban gymnastics, extreme tumbling, tricking, free-running and/or similar type of programs/activities?

Yes

The use of projectile weapons including, but not limited to, firearms and tasers, and defense sprays along with sharpened/bladed weapons are excluded from coverage under this policy.

Accept and continue

Decline and Exit

Does your facility include any of the below operations?

Yes

• Acupuncture or acupressure • Licensed daycare • Massage Therapy • Sharpened or Bladed Weapons • Trampoline Parks / Facilities • Transportation of participants

If so, which ones?*

Do you utilize any inflatable devices?*

Yes

Open Studio

Do you have open gym/studio time?*

Yes

Is your open gym/studio time limited to your members only?*

Yes

Is open gym/studio time supervised by staff members at all times?*

Yes

Hiring

Do you employ independent contractors?*

Yes

Are all instructors employees of the Named Insured business?*

Yes

-Please confirm you understand coverage does not extend to independent contractor instructors (non-employees).*

Decline

If you suspect a participant has a concussion, do you have an action plan that includes:

-Immediately removing the athlete from play or practice?*

Yes

-Keeping the athlete out of play or practice until they provide written clearance from a licensed physician?*

Yes

Confirming sports liability waivers (informed consent) from parents and/or players are secured.*

Yes

Do you maintain a system for your activities that includes communication (in written or electronic form) of education materials to participants, parents and coaches about the nature of risk of concussions, including but not limited to information such as: focusing on prevention and preparedness to keep athletes safe; understanding concussions and potential consequences of the injury; recognizing concussion symptoms and how to respond; and learning about steps for returning to play after a suspected concussion?*

Yes

Information for coaches and parents The Center for Disease Control and Prevention offers free information, as well as a free concussion training course on their website:

www.cdc.gov/concussion

Do you offer any activities or programs other than martial arts and/or those listed above?

Yes

Would you like to add Non-Owned and Hired Automobile coverage?*

Yes

*No coverage for transportation of athletes* Non-Owned and Hired Automobile coverage provides liability coverage for rented, hired, borrowed or other autos that you do not own that are used in connection with your business. Coverage is not included for physical damage to the auto itself. Coverage excludes transportation of athletes.

Would you like to add Abuse and Molestation coverage?*

$100,000 Limit

*Defense cost included within limit* Abuse and Molestation coverage provides coverage for allegations of sexual abuse and molestation. Coverage is provided for judgments as well as for expenses to investigate and defend an allegation of abuse. However, both judgment and defense costs reduce the available limit.

Would you like to increase your accident medical limit to $100,000?*

Yes

Would you like a quote for optional Business Property coverage?*

Yes

Does your landlord/lease agreement require you to carry coverage for plate glass? If so, would you like to add $25,000 of plate glass coverage for $250 additional premium?*

Yes

Please Note: When you choose limits of insurance below, please keep in mind that most banks, landlords and the insurance company require that you insure 100% of the replacement cost value of all contents and equipment.

Business Interruption limit*

Business Interruption – In the event that you cannot operate (ex: a fire in the studio which causes you to shut down), how much money do you need to cover your ongoing expenses such as rent, payroll, lost revenue, and utilities while the renovation is being completed?

Contents and Equipment Limit*

Contents & Equipment – for this limit, you will want to think about items you have in the studio such as your mats, weights, Bosu balls, reformers, heating elements, merchandise, office equipment, iPad, laptops, A/V equipment, etc.) plus your plate glass and signage. If you have a total loss and have to replace all of these items, how much money would you need?

Tenant Improvements (Buildout Amount)*

Please enter a number greater than or equal to 0.

Tenant Improvements & Betterments (TIB) – this is your buildout amount. For example, if your studio was to burn down, how much money would you need to rebuild? If you do not yet have a firm quote for your buildout, you may want to purchase a conservative limit with the understanding that you will need to raise the limit for additional premium once the final buildout costs are available.

What type of construction is your Martial Arts facility in?*

Fire Resistive Construction (includes Masonry Non-Combustible): Mostly structural steel with brick and masonry. Concrete walls with steel framing (commonly found in strip malls).

Framed Construction: Mostly wood with some supporting beams and columns (similar to a residential home).

Joisted Masonry / Non-Combustible: Combination of wood and concrete construction. Found in small office buildings.

Would you like to purchase optional excess/umbrella coverage?

Yes

If so, please select a limit from the list

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

Policyholder Info

Policyholder name

First Last

Policyholder DBA

Policyholder mailing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name*

First Last

Email*

Phone*

Organization entity type*

LLC

Individual

C Corporation

S Corporation

Partnership

Limited Partnership

Joint Venture

Sole Proprietorship

Other

Website (if applicable)

Fraud Notice*

Yes

The applicant hereby represents and confirms that the information provided, to the best of the applicant’s knowledge, is true and correct and further certifies that applicant has read all of the questions and answers on this application. The applicant understands that incorrect information could void the insurance coverage. The applicant understands that any false or misleading information on this application may be subject to criminal and civil penalties. Any person, who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. Applicant confirms that he/she has read and understands the individual state fraud notices which are a part of this application for insurance coverage. Applicant acknowledges and understands that any person or persons who knowingly and with intent to defraud any insurance company commits a fraudulent insurance act, which is a crime, is subject to criminal and civil penalties. Fraud Notice THIS NOTICE IS PART OF YOUR INSURANCE APPLICATION. Alabama, Alaska, Arizona, California, Connecticut, Delaware, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, North Carolina, North Dakota, Rhode Island, South Carolina, South Dakota, Texas, Utah, West Virginia, Wisconsin, Wyoming “Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.” Arkansas Fraud Statement "Any person who knowing presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison." Colorado Fraud Statement "It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies." District of Columbia Fraud Statement "Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant." Florida Fraud Statement "Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree." Hawaii Fraud Statement “For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.” Kentucky Fraud Statement "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime." Louisiana and New Mexico Fraud Statement "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties." Maine Fraud Statement "It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits." Maryland Fraud Statement “Any person who knowingly and willfully presents a fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.” Massachusetts, Nebraska, Oregon and Vermont Statement “Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.” New Jersey Fraud Statement "Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties." New York Fraud Statement "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information 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." Ohio Fraud Statement "Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud." Oklahoma Fraud Statement "Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony." Pennsylvania Fraud Statement "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties." Tennessee, Virginia and Washington Fraud Statement "It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits."

Purchasing Group Agreement*

Yes

This American Specialty Sports & Entertainment Purchasing Group has been organized as a purchasing group in Indiana, pursuant to legislation enacted by the US Congress as the Federal Liability Risk Retention Act of 1986. You become a member of the purchasing group once your completed application has been approved and your membership fee and premium payment are received.

**Important: Please note completion of any request(s) for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting a request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.