Business Owners Policy Application

1. Your Information

Effective Date:

Business Name (Legal):

DBA:

Insured’s Name:

Date of Birth:

Type of Business Entity: CorporationLLCPartnershipIndividual/Sole Proprietor

If LLC, Number of Managers, LLC Members and Executive Officers:

If Corporation, Number of Executive Officers:

How did you hear about us?

2. Business Information

Business Address:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Website:

Phone:*

Email:*

Business Description:

Year Business Started:

FED Tax ID:

Days/Hours of Operation:

Expected Annual Sales:*

Annual sales are primarily from: Instructor-led classesIndividual workouts

Year Building Constructed:

Do you offer personal or group training? YesNo

Number of employees (don’t include owner(s) or independent contractors):

Number of employees who are personal or group trainers:

Number of independent contractors who are personal or group trainers:

Do you require independent contractors to carry their own General Professional Liability Insurance policy? YesNo

Total number of owners, employees and independent contractors:

3. Business Details

4. Building Details

5. Prior Insurance

BUSINESS OWNERS POLICY APPLICATION