Health Club Park District Individual
Does your organization utilize a waiver system? Yes No
Does your organization have a risk management plan? Yes No
Does the property where you are conducting the activity require a Certificate of Insurance (additional insured)? Yes No
What styles of dance are taught? Please be specific. *
Has your past liability insurance been canceled in any ways in the last three years? If so, please be specific.
List additional insured name(s) and address(es)
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Premium is fully earned on the effective date of coverage. No pro-rata refunds will be made. Cancellation requests prior to the effective date must be in writing and subject to a minimum cancellation fee of $75.00. I understand and agree that (a) if this application is accepted by the Company, coverage will begin on the date of acceptance or the date requested in the application, whichever is later, subject to payment of the required premium; and (b) Premium computation is subject to audit. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
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