Dance Schools and Studios

Part I: Proposed Policyholder

Policyholder
Full Legal Name
(as it will appear on the policy documents)
Type of Operation
Mailing Address
City
State   Zip
Is this Mailing Address also a Studio Location where classes will be held? Yes No
Contact Information
First Name Middle Last Name
Phone Number
Email
Studio Location(s)
Studio Location #1
Mailing Address
City
State   Zip

Part II: Policy Term

12 months of coverage is provided
to

Part III: Accident Plan of Insurance

Plan of Benefits
Accidental Death & Dismemberment Principal Sum
Accidental Death & Dismemberment Aggregate
Maximum Medical Expense Benefit
Deductible Amount

Part IV: General Liability Questionnaire

1.Has your past liability coverage been canceled in any way in the last three years? Yes No
2.A Participant Waiver Is Required to be In Place in Order to Obtain Coverage. Please confirm you will comply with this requirement. Yes No
3.Does your organization have a written safety plan or risk management plan in place? (For example: Emergency Procedures, Written/Posted Rules and/or Regulations, Code of Conduct, Consent Form, Emergency Contact Form)What is it? Yes No
4.Is your current insurer non-renewing coverage? Yes No
5.Have any liability claims been paid by your insurer during the last 3 years? Yes No
6.Please select the style(s) of dance taught in your facility (select all that apply):
7.Do you offer pole or aerial dance? Yes No
8.Do you offer circus skills training? Yes No
9.Do you have any programs involving gymnastics, cheerleading, extreme tumbling? Yes No
10.Are you a professional dance/touring company? Yes No
11.Do you operate a nightclub, banquet/dance/reception hall, or discotheques? Yes No
12.Does your facility have an inflatable device? Yes No
13.Does your facility have playground equipment? Yes No
14.Do you have any activities/operations taking place at a residential location? Yes No

Part V: General Liability Limits

Limit Per Occurrence
Aggregate Limit
Abuse or Molestation Limit
Professional Liability Limit

Part VI: Premium Calculation

Number of students in the busiest month of the year X =
Minimum Premium
Does your organization host birthday parties? Yes No
Sub Total
Minimum premium is fully earned upon inception.
Optional Coverages Premiums are fully earned upon inception

Hired and Non-Owned Automobile Liability Coverage =
$1,000,000 Hired and Non-Owned Automobile Liability Coverage is available but subject to
additional underwriting. Please contact your agent if wishing to apply for coverage.
(12 plus passenger vans are ineligible for this program)
Medical Payments Coverage =
Higher Abuse or Molestation Limit
Higher Abuse or Molestation limit of $1,000,000 is available but subject to additional underwriting.
Please contact your agent if wishing to apply for coverage.
Equipment Coverage
Equipment Coverage is available but subject to additional underwriting.
Please contact your agent if wishing to apply for coverage.
Excess Coverage
Higher per occurrence limits of up to $4,000,000 are available but subject to additional underwriting.
Please contact your agent if wishing to apply for coverage.

Part VII: Additional Insureds

Add Additional Insured
First Name   Last Name  
Legal Name
Mailing Address
City   State   Zip
Email:
Relationship:

Part VIII: Hosted Events

If your organization hosts any Dance Tournaments, Seminars, Camps and/or Field Trip activities, please complete this section to have your policy endorsed to include these activities.
Events Information
Event #1 Clear
Event Name Event Type Number of Participants
Location of Event Location Address
Event Start Date Event End Date
     Please note: Camps or Field Trips may be up to one year long. Tournaments or Seminars may be up to 3 consecutive days only.
Event Premium
Exclusions

Exclusions for Commercial General Liability Coverage, include but are not limited to the following:

Access or Disclosure of Confidential or Personal Information and data-Related Liability – With Limited Bodily Injury Exception, Coverage C – Medical Payments, Employment Related Practices Exclusion, Fungi or Bacteria, Exclusion of Other Acts of Terrorism Committed Outside the United States; CAP on Losses from Certified Acts of Terrorism, Exclusion of Punitive Damages Related to Terrorism, Liability Arising Out of Lead, Silica or Related Dust Exclusion, Nuclear, Biological, or Chemical Exclusion, Failure to Provide Waiver and Release Sublimit, Exclusion – Organic Pathogens. All of the above are subject to the terms and conditions of the policy.

Excluded activities:

The ownership, operation, maintenance arising out of the use of inflatable recreational devices or inflatable amusement devices of any kind.

Any use, event or display arising out of fireworks, or any other use of pyrotechnics including any firework sales.

Any use, handling, training, or storage of any firearms, ammunition, or explosives.

Any operations involving bungee devices (except for indoor bungee fitness), carnival rides, corn cannons, organized equine racing contests, organized equine vaulting or jumping contests, leasing of horses, jumping pillows, knocker ball, bubble soccer, Zorb ball, paintball, airsoft, mechanical bucking devices including multi-ride attachments, aerial activities above 12 feet, rock climbing activities, activities involving permanent or mobile rock wall climbing structures, zip lines, pumpkin launching devices, rope challenge courses, water skiing, surfing, white water rafting or kayaking, tackle football, ATV/UTV, tracked or trackless train rides, trampolines, bike related trick or stunt activities or contests, Zippy Pets, haunted houses, haunted trails or haunted boats or barges, demolition derbies of any kind, independent security services other than a contracted public law enforcement officers.

Trail design, including trail construction and maintenance, Participants of Mixed Martial Arts (MMA) competitions or tournaments, Participants of boxing competitions or tournaments, Participants of bare-knuckle boxing, Any use of sharpened or live edged weapons, Security Officers Registration Act (SORA) training programs, WWE style fight training, professional fight training, professional fighting participants, Operations of independent concessionaires or vendors in conjunction with your organization or event, Operations of independent performers and artists in conjunction with your organization or event, Use of gymnastics apparatuses, including balance beams, uneven bars, vaults, spring flooring, and rings, Aerial activities and performances other than studio sponsored recitals with maximum heights of 12 feet.

Exclusions for Accident Coverage:

This plan does not cover any loss to or resulting from: suicide, self-destruction, attempted self-destruction or intentional self-inflicted injury while sane or insane. War or any act of war, declared or undeclared. Sickness, disease or any bacterial infection, except one that results from an accidental cut or wound or pyogenic infections that result from accidental ingestion of contaminated substances. Voluntarily taking any drug or narcotic unless the drug or narcotic is prescribed by a Physician. Covered Expenses for which the Covered Person would not be responsible in the absence of this Policy. Injuries paid under Workers' Compensation, Employer's liability laws or similar occupational benefits or while engaging in activity for monetary gain from sources other than the Policyholder. Injury caused by, contributed to or resulting from the Covered Person's use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person's Physician. Service or Active Duty in the armed forces, National Guard, military, naval or air service or organized reserve corps of any country or international organization. Services or treatment rendered by a Physician, Nurse or any other person who is employed or retained by the policyholder; or an Immediate Family member of the Covered Person. Treatment of a hernia, Osgood-Schlatter's disease, osteochondritis, appendicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, whether or not caused by a Covered Accident. Damage to or loss of dentures or bridges or damage to existing orthodontic equipment, except as specifically provided in this Policy. Eyeglasses, contact lenses, hearing aids. Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from: While riding as a passenger in any aircraft not intended or licensed for the transportation of passengers.

Acknowledgements and Signatures
  1. Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which may be a crime.
  2. Waiver Requirement Each policyholder must implement a Release and Waiver of Liability and Indemnity Agreement for all participants and staff members. Unintentional error on your part in securing Waiver and Release forms shall not void your coverage in the event of an occurrence to a participant 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 a participant or staff member. A full supply of Waiver and Release forms shall be shipped to your policyholder upon request.
  3. Applicant’s Acknowledgement I, the applicant, declare, to the best of my knowledge and belief, that all statements and answers in this application are 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.

To sign the application, check the Digital Signature checkbox below:

User's Name