Download Brochure Quote Request Form Personal Trainer Application Step 1 of 5 20% HiddenTag Name First Last Date of Birth MM slash DD slash YYYY Are you 18 or older?SelectYesNoAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone(Required)Email(Required) Consent(Required) I agreeBy providing my wireless phone number to Rosenthal Insurance Services, Inc., I agree and acknowledge that Rosenthal Insurance Services, Inc. may send text messages to my wireless phone number for any purpose, including marketing purposes. Requested Effective Date MM slash DD slash YYYY Has your past liability coverage been cancelled in any way in the last three years? If so, please be specific.SelectYesNoCancellation reason Do you currently have a risk management plan?SelectYesNoDo you currently utilize a waiver system?SelectYesNo Are you a certified fitness instructor?SelectYesNoWhich accredited certificate do you have?SelectAAAI-ISMAAAPTEACEACSMAFAAAFPACIHFPAIARTIPTAISFDISFTAISSANABFNASMNCCPTNCSFNESTANETANFPTNSCANSPAPFITSIEPUSCIWITSOther (200 Hours Minimum)Describe Accredited Certificate Drop files here or Select files Max. file size: 50 MB. Type of Instructor Tae Bo Exercise Gyrotonic Strength Aerobics Stroller Strides Dancercise Spinning Personal Training Pilates Aquatic Exercise Tai Chi Yoga Cardio Kickboxing Childrens Fitness Programs Fitness Bootcamp Years of accredited experience? Maximum number of clients at one time? Description of instructor activitiesLocations of training?Do the locations carry liability insurance?SelectYesNoGeneral Aggregate $1,000,000 $2,000,000 Limit Per Occurrence $1,000,000 $1,000,000 Accredited Certified Fitness Instructor $169.00 $179.00 Non-Accredited Certified Fitness Instructor $259.00 $269.00Please choose liability limitSelect$1,000,000/$1,000,000$1,000,000/$2,000,000Please choose the rate that appliesSelectAccredited Certified Fitness InstructorNon-Accredited Certified Fitness Instructor Optional $150,000.00 hired and non-owned automobile liability coverage is available for an additional $225.00.SelectYesNoOptional $500,000.00 hired and non-owned automobile liability coverage is available for an additional $500.00. • Note: $1,000,000.00 hired and non-owned automobile liability coverage is available but subject to additional underwriting. Please contact your agent if wishing to apply for coverage.SelectYesNoOptional $100,000.00 sexual abuse and molestation liability coverage is available for an additional $1,000.00.SelectYesNoOptional $5,000.00 medical expense benefit 2% of Part II Premium SubtotalSelectYesNoDo you have any venues that require additional insureds?SelectYesNoName of Venue Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Any other venues?SelectYesNoName of Venue 2 Address of venue 2 Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code This summary of coverage and exclusions is no substitute for reading the entire policy. To receive an entire policy, contact the program administrator. Waiver RequirementEach school or studio must implement a Release and Waiver of Liability and Indemnity Agreement for all students and staff members. Unintentional erroron your part in securing Waiver and Release forms shall not void your coverage in the event of an occurrence to a student or staff member. However,your failure to maintain an adequate system to regularly secure Waiver and Release forms shall void your coverage in the event of an occurrence to astudent or staff member. A full supply of Waiver and Release forms shall be shipped to your school or studio upon request. Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance orstatement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact materialthere to, commits a fraudulent insurance act, which may be a crime. Applicant’s Acknowledgement I, the applicant, declare, to the best of my knowledge and belief, that all statements and answers in this applicationare true and complete. I understand and agree that (a) this application will form part of any policy issued,(b) no information given to or acquired by any representative of the Company will bind it, unless it is in writing on this application,(c) no waiver or modification will bind the Company unless it is in writing and is signed by an executive officer of the Company, and(d) only those persons eligible under the terms of an issued policy will be insured. Type Name for Signature(Required) Date Signed MM slash DD slash YYYY
