Are you 18 or older?
*
You must be 18 years of age or older to qualify
Yes
No
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Requested Effective Date of Coverage
*
Has your past liability coverage been cancelled in any way in the last three years?
*
Yes
No
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Please specify why coverage has been cancelled
Do you currently have a risk management plan?
*
Yes
No
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Do you currently utilize a waiver system?
*
Yes
No
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Are you a certified fitness instructor?
*
Yes
No
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Which accredited certificate do you have?
*
None
AAAI-ISMA
AAPTE
ACE
ACSM
AFAA
AFPA
CI
HFPA
IART
IFPA
IPTA
ISFD
ISFTA
ISSA
NABF
NAFC
NAFTA
NASM
NCPT
NCCPT
NCSF
NESTA
NETA
NFPT
NSCA
NSPA
PFIT
SIEP
USCI
WITS
Other (200 hours minimum)
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Other (200 hours minimum) - Please specify
Please make sure to provide a copy of your certificate with application.
. You can take a picture of your certificate and upload the image here.
* Please note that we can only accept licenses from the listed accredited fitness instructor certifications or one with a minimum of 200 hours of training. Any other certifications will need to use the non-certified rate.
Estimated number of clients annually
*
1 to 25
25 to 50
50 to 75
75 to 100
100 to 125
125 to 150
150 to 175
175 to 200
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Type of instructor
*
Check all that apply
Tae Bo
Exercise
Gyrotonic
Strength
Aerobics
Stroller Strides
Dancercise
Spinning
Personal Training
Pilates
Aquatic Exercise
Tai Chi
Yoga
Cardio Kickboxing
Children’s Fitness Programs
Fitness Bootcamp
Other
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Type of Instructor Other (describe in detail)
Years of accredited experience?
0
1
2
3
4
5
6
7
8
9
10
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* Please note that Aerial Instruction is not covered under this program. Please contact our office to receive a quotation:
Description of instructor activities
Location(s) of training
Does the location(s) carry liability insurance?
Yes
No
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Are you an Accredited Certified Fitness Instructor?
*
Yes
No
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General Aggregate Limits
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
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Optional $150,000.00 hired and non-owned automobile liability coverage is available for an additional $225.00.
Yes
No
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Follow form excess liability limits of up to $4,000,000.00 are available but subject to additional underwriting. Please contact your agent if wishing to apply for coverage.
Yes
No
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Equipment coverage up to $750,000.00 is available but subject to additional underwriting. Please contact your agent if wishing to apply for coverage.
Yes
No
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Fitness Instructor's Company Name
Fitness Instructor's First Name
Fitness Instructor's Last Name
Fitness Instructor's Address
City
State
ZIP
Phone (where quote and option to buy will be submitted)
*
Email (where quote and option to buy will be submitted)
*