health club pkg gl pl rou040 201104
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
HEALTH CLUB PAK PROGRAM APPLICATION General and Professional Liability NOTE: To add Commercial Property, Crime or Inland Marine, attach appropriate ACORD applications or equivalent.
APPLICANT INFORMATION Name Address City, State, Zip
Policy Term
Telephone
Professional License Type and Number (if required)
Business Organization:
Individual
Partnership
Corporation
GL & Prof. Limits Requested: Occurrence
Other
Personal Injury/Advertising
General Aggregate
Medical Payments
Prods/Comp Ops Aggregate
Fire Legal
Estimated annual payroll $
Estimated annual receipts $
Number of Full-time employees
Part-time
Years in business
Independent Contractors
Other
List licensing certification requirements (For instructor only, teaching certification achieved) ________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Check services provided: Whirlpool
Racquetball, Tennis, Handball
Aerobics
Jogging track
Free weights
Sauna, Steam Room
Nautilus-Universal weight machines
Stationary bikes, Rowing machines
Swimming pools (attach specifics)
Tanning beds (attach supplemental application)
Other (Be Specific) Martial Arts (Describe) Number of students
Type of weapons taught
If students participate in tournaments, explain number, ages, type of contact, etc.) ___________________________________________________________________________________ Provide a copy of membership contract. Describe any products sold on premises
________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
SAVE rou040-201104
Page 1 of 2
Royal Oak Underwriters, Inc.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
THREE YEAR LOSS EXPERIENCE Date
Losses (description and amounts paid and incurred)
____________
__________________________________________________________________________
____________
__________________________________________________________________________
____________
__________________________________________________________________________
Comments
Applicant Signature
Producer Name & Address
______________________________________ Date COVERAGE IS NOT BOUND UNTIL APPROVED BY THE COMPANY
Reset Form rou040-201104
Page 2 of 2
Submit by E-mail
Print Form
SAVE
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
HEALTH CLUB PAK PROGRAM APPLICATION General and Professional Liability NOTE: To add Commercial Property, Crime or Inland Marine, attach appropriate ACORD applications or equivalent.
APPLICANT INFORMATION Name Address City, State, Zip
Policy Term
Telephone
Professional License Type and Number (if required)
Business Organization:
Individual
Partnership
Corporation
GL & Prof. Limits Requested: Occurrence
Other
Personal Injury/Advertising
General Aggregate
Medical Payments
Prods/Comp Ops Aggregate
Fire Legal
Estimated annual payroll $
Estimated annual receipts $
Number of Full-time employees
Part-time
Years in business
Independent Contractors
Other
List licensing certification requirements (For instructor only, teaching certification achieved) ________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Check services provided: Whirlpool
Racquetball, Tennis, Handball
Aerobics
Jogging track
Free weights
Sauna, Steam Room
Nautilus-Universal weight machines
Stationary bikes, Rowing machines
Swimming pools (attach specifics)
Tanning beds (attach supplemental application)
Other (Be Specific) Martial Arts (Describe) Number of students
Type of weapons taught
If students participate in tournaments, explain number, ages, type of contact, etc.) ___________________________________________________________________________________ Provide a copy of membership contract. Describe any products sold on premises
________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
SAVE rou040-201104
Page 1 of 2
Royal Oak Underwriters, Inc.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
THREE YEAR LOSS EXPERIENCE Date
Losses (description and amounts paid and incurred)
____________
__________________________________________________________________________
____________
__________________________________________________________________________
____________
__________________________________________________________________________
Comments
Applicant Signature
Producer Name & Address
______________________________________ Date COVERAGE IS NOT BOUND UNTIL APPROVED BY THE COMPANY
Reset Form rou040-201104
Page 2 of 2
Submit by E-mail
Print Form
SAVE
Royal Oak Underwriters, Inc.
