Completing this application does not put coverage in force.
No coverage will be effective until a policy is quoted by
one of our agents, and that quote is accepted, and the
appropriate down payment is made.
Name of the legal Entity:
Trade Name (if different):
Type of Business:
Corporation Individual LLC Partnership
Other (Explain):
Mailing Address (Street, City, State, & Zip)
Contact Name & Phone Number
Fax Number & Email Address
List all styles routinely taught at the school:
Estimated number of students annually:
Total annual receipts from membership fees/tuition:
Belt rank of chief instructor:
Do you require a signed Hold Harmless agreement from
students (or from parents, if a minor)? Yes No
If Yes, either email agreement to brownsins@aol.com
or mail a copy to the address above.
Does the school engage in sparring? Yes No
If Yes, either email sparring rules to brownsins@aol.com
or mail a copy to the address above.
Does the school engage in boxing? Yes No
Does the school engage in kickboxing? Yes No
Is there any sparring with weapons? Yes No
(Contact with weapons unacceptable)
What type of weapons are taught (please be specific)?
What belt rank must a student hold before learning the
use of such weapons (if rank varies, furnish details)?
Does the school sponsor, stage, or host tournaments? Yes No
(If tournament coverage is desired for staging, hosting
or sponsoring please complete our MARTIAL ARTS
TOURNAMENT QUESTIONNAIRE after completing
and sending this form.)
Name of federation or association the school is affiliated with:
What type of floor surface is in the area on which classes are taught?
Age range of Students:
From years old to years old.
General Liability Limits Desired:
$500,000 (minimum) $1,000,000
Umbrella Liability Limits Desired:
None $1,000,000 $2,000,000
$3,000,000 $4,000,000 $5,000,000
FACILITY LOCATION(S):
(Spaces for 4 locations are provided below. If more than 4, please submit a second form.)
Location 1 Address (Street, City, State, & Zip)
Estimated cost to replace all furniture, fixtures, and tenants
improvements
If building is owned, cost to replace building
(Enter 'Not Needed' if applicable)
Construction of building:
frame
brick with wood rafters
brick with concrete and steel roof
metal & concrete
Distance to fire Hydrant:
under 1000 feet
over 1000 feet
Distance to Fire Department:
under 5 miles over 5 miles
Location 2 Address (Street, City, State, & Zip)
Estimated cost to replace all furniture, fixtures, and tenants
improvements
If building is owned, cost to replace building
(Enter 'Not Needed' if applicable)
Construction of building:
frame
brick with wood rafters
brick with concrete and steel roof
metal & concrete
Distance to fire Hydrant:
under 1000 feet
over 1000 feet
Distance to Fire Department:
under 5 miles over 5 miles
Location 3 Address (Street, City, State, & Zip)
Estimated cost to replace all furniture, fixtures, and tenants
improvements
If building is owned, cost to replace building
(Enter 'Not Needed' if applicable)
Construction of building:
frame
brick with wood rafters
brick with concrete and steel roof
metal & concrete
Distance to fire Hydrant:
under 1000 feet
over 1000 feet
Distance to Fire Department:
under 5 miles over 5 miles
Location 4 Address (Street, City, State, & Zip)
Estimated cost to replace all furniture, fixtures, and tenants
improvements
If building is owned, cost to replace building
(Enter 'Not Needed' if applicable)
Construction of building:
frame
brick with wood rafters
brick with concrete and steel roof
metal & concrete
Distance to fire Hydrant:
under 1000 feet
over 1000 feet
Distance to Fire Department:
under 5 miles over 5 miles
CURRENT GENERAL LIABILITY INSURANCE COMPANY:
Name of Current Insurance:
Current Annual Premium:
Any claims in the last 3 years? Yes No
Effective date needed:
CURRENT WORK COMP INSURANCE COMPANY:
Name of Current Insurance:
Current Annual Premium:
Any claims in the last 3 years? Yes No
Effective date needed:
CURRENT PROPERTY INSURANCE COMPANY:
Name of Current Insurance:
Current Annual Premium:
Any claims in the last 3 years? Yes No
Effective date needed:
CURRENT AUTO INSURANCE COMPANY:
Name of Current Insurance:
Current Annual Premium:
Any claims in the last 3 years? Yes No
Effective date needed:
Website address (if any):
Applicant's Name:
Today's Date:
Add remarks or additional information that you think is important for
us to provide a quote. Include description and amount of any claims.
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