[Canadian] Individual Fitness/Yoga/Pilates/Martial Arts Instructor Application

	Warning: Errors!! The application was not submitted due to the fact that some fields were missing or not filled in properly. Please follow the symbol and re-enter or review your answer. Note: If the question for a required text input field is inapplicable, please indicate this, by for example, entering 'N/A'.

Request Date    09/10/2010 06:43:37 AM

Named Insured
Address
	City
	Province
	Country
	Postal code
Contact Name
	Telephone Number
	Fax
	Email
Form of business:			Corporation Individual Joint Venture/Partnership Registered Non Profit Assn Other
Are you a member of a professional association related to your occupation?   Yes No I understand that this application is for my operations as a instructor only, I do not occupy my own studio space   Yes No
Please specify Instruction type			Martial Arts Fitness Pilates Yoga
Please select type Aikido Jiu Jitsu Judo Karate Kendo Kung Fu Mixed Martial Arts Tae Kwon Do Tai Chi Other   Please describe the Sport/Activity:   Describe sparring style No Contact Contact to Focus/Thai/Target Pads only Light Contact to body, none to head Light Contact to body and head Full Body Contact Ring Style Sparring   Mandatory Safety equipment: Head Protection   Yes No Mouth Guard   Yes No Pads   Yes No   Weapons are: Authentic Foam/Plastic/Wood Not Used   Number of students If cover for another sport/activity is sought, please check next next   Please select type (2) Aikido Jiu Jitsu Judo Karate Kendo Kung Fu Mixed Martial Arts Tae Kwon Do Tai Chi Other   Please describe the Sport/Activity: (2)   Describe sparring style (2) No Contact Contact to Focus/Thai/Target Pads only Light Contact to body, none to head Light Contact to body and head Full Body Contact Ring Style Sparring   Mandatory Safety equipment: Head Protection   Yes No Mouth Guard   Yes No Pads   Yes No   Weapons are: (2) Authentic Foam/Plastic/Wood Not Used   Number of students (2) If cover for another sport/activity is sought, please check next next   Please select type (3) Aikido Jiu Jitsu Judo Karate Kendo Kung Fu Mixed Martial Arts Tae Kwon Do Tai Chi Other   Please describe the Sport/Activity: (3)   Describe sparring style (3) No Contact Contact to Focus/Thai/Target Pads only Light Contact to body, none to head Light Contact to body and head Full Body Contact Ring Style Sparring   Mandatory Safety equipment: Head Protection   Yes No Mouth Guard   Yes No Pads   Yes No   Weapons are: (3) Authentic Foam/Plastic/Wood Not Used   Number of students (3) If cover for another sport/activity is sought, please check next next   Please select type (4) Aikido Jiu Jitsu Judo Karate Kendo Kung Fu Mixed Martial Arts Tae Kwon Do Tai Chi Other   Please describe the Sport/Activity: (4)   Describe sparring style (4) No Contact Contact to Focus/Thai/Target Pads only Light Contact to body, none to head Light Contact to body and head Full Body Contact Ring Style Sparring   Mandatory Safety equipment: Head Protection   Yes No Mouth Guard   Yes No Pads   Yes No   Weapons are: (4) Authentic Foam/Plastic/Wood Not Used   Number of students (4) If cover for another sport/activity is sought, please check next next   Please select type (5) Aikido Jiu Jitsu Judo Karate Kendo Kung Fu Mixed Martial Arts Tae Kwon Do Tai Chi Other   Please describe the Sport/Activity: (5)   Describe sparring style (5) No Contact Contact to Focus/Thai/Target Pads only Light Contact to body, none to head Light Contact to body and head Full Body Contact Ring Style Sparring   Mandatory Safety equipment: Head Protection   Yes No Mouth Guard   Yes No Pads   Yes No   Weapons are: (5) Authentic Foam/Plastic/Wood Not Used   Number of students (5) If you require coverage for more Sports/Activities than specified above, please contact us
Please select your certification/licensing body BCRPA Can-Fit Pro ISSA ACE CSAP IDEA AFFA Kinesiology/Phys Ed Degree Other Please specify
Please select your certification/licensing body Balanced Body BASI Boulder Classical Pilates Peak Pilates PhysicalMind Institute PMA Polestar Ron Fletcher Romana's Pilates Stott Pilates Other Please specify
Do You Practice hot yoga?   Yes No Please select your certification/licensing body Ashtanga Bikram Hatha Iyengar Kundalini Power Vinyasa Yin CYA YABC Other Please specify
Number of hours worked per week			10 or fewer 11 or more
EFFECTIVE DATE
EXPIRY DATE
Limits of Liability			$ 2,000,000.00 $ 5,000,000.00

Have you had losses due to liability claims in the past 3 years?

Yes No

If yes, please list any claims for the past 3 years:

Have you ever filed for bankruptcy?

Yes No

If yes, please explain:

Has insurance ever been declined or cancelled for any reason?

Yes No

If insurance has been declined or cancelled, please explain:

Does the applicant require certificate(s) for Additional Insureds?

Yes No

Additionally Insured Certificate (1) :
Name (to appear on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility
More Additional Insureds

Additionally Insured Certificate (2) :
Name (to appear on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility
More Additional Insureds

Additionally Insured Certificate (3) :
Name (to appear on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility
More Additional Insureds

Additionally Insured Certificate (4) :
Name (to appear on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility
More Additional Insureds

Additionally Insured Certificate (5) :
Name (to appear on certificate)
Address
City
State/Province
Country
Zip/Postal code
Contact Name
Phone Number
Fax Number
E-mail
Type of Business:
Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility
If you require certificates for more Additional Insureds than specified above, please contact us