Individual Fitness Trainer Insurance Application Form

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Are you a broker? *

Contact Name

Broker Email

Broker Phone

Brokerage Name

Brokerage Address

Name

Mailing Address:

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City:

Postal Code:

Prov:

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Phone: Home *

Phone: Work

Email: *

Website:

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Business Name

Incorporated/Limited Company?

List Your Certifications Here: **YOU MUST REMIT A COPY OF EACH CERTIFICATION**

Certification Files Upload

Click or drag files to this area to upload. You can upload up to 5 files.

TRAINER ELIGIBILITY CHECKLIST - Please answer the following questions:

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Do you have employees or sub-contractors?

Are you CrossFit certified/Instructing CrossFit?

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Are you doing any work outside of Canada?

Are you working with children under 12 years?

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Do you require equipment damage coverage?

Do you have any clients coming into your home?

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Do you own or have you signed a lease for any commercial property that you work out of?

Have you had any prior claims?

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Are you working with Semi-Prof/Prof Athletes?

Do you organize/host any special events/retreats?

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Do you offer partner yoga?

Are you an Instructor/Master Trainer (certify others)?

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Do you offer any training/instruction other than face-to-face/in person (Zoom, Skype, etc.)?

Are you working with any active rehabilitation patients?

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Are you working with any post rehabilitation patients?

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Do you sell supplements (Isagenix, USANA, etc.)?

What are your total annual gross receipts? (If unsure, please estimate)

Policy Coverages and Extensions

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Comprehensive Liability

Provides premises/operation protection for any claims arising from your fitness related activities including sexual harassment.

Personal Injury Liability

Protects you against suits involving libel, slander, wrongful invasion of privacy, etc.

Tenant’s Legal Liability

Provides $250,000 of tenant’s legal liability protection for any claims arising from facilities you rent, lease, or occupy.

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Coverage

Deductible

Limit

Liability - Occurrence Basis (including Professional)

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Coverage A – Bodily Injury and Property Damage

$0*/ $500

$2,000,000 ‡

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Coverage B – Personal and Advertising Injury

$2,000,000 ‡

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Coverage C – Medical Payments – Any one person/Any one claim

$25,000/$25,000

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Coverage D – Tenants’ Legal Liability

$500

$250,000

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General Aggregate Limit

$5,000,000

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Products-Completed Operations Aggregate Limit

$2,000,000 ‡

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Abuse Limitation

$250,000

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Additional Insured – Certificate Holders Endorsement

Included

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Accident, Heart Attack and Stroke Insurance

As Per Endorsement

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Martial Arts Studio Endorsement

Included

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Retroactive Date Endorsement

Included

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Hypnotherapy Extension Endorsement

Included

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Beauty/Esthetics and Spas – Exclusions, Conditions, Restrictions and Warranties

Included

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Cyber and Data Total Exclusion Endorsement

Included

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Communicable Disease Exclusion

Included

‡ Higher Liability Limits are available
* Bodily Injury Deductible subject to change depending on operations performed

Terms and Acknowledgements:

This program is based on 1 instructor (yourself) only. If additional employees or contract trainers are hired we must be notified and
policy & premium changes may be made.

It is required that all certifications will be kept valid/updated at all times.

It is required that a Get Active questionnaire, Med X, or similar questionnaire is completed and kept on file for all clients.

Any changes to operations or services from the information contained in this application are required to be disclosed to Sports &
Fitness Insurance Canada for review of program eligibility. This may result in changes to premium, program, or cancellation of
coverage.

A waiver must be signed and kept on file for at least 2 years (minors: 2 years after participant reaches the legal age of majority).
coverage.

This policy will be fully earned. There will be no refund once the policy is bound.

There must be a log book in force to document all incidents and correspondence/follow ups.

All incidents will be reported to claims@sportsfitnesscanada.com immediately.

This policy will be bound upon verification of eligibility, valid certification, and payment.

I confirm that all information above is true and accurate, and understand that the PREMIUM IS FULLY EARNED and there are no refunds once policy is bound.

I understand and agree that any policy issued will be based upon the information contained in the application and any related forms and correspondence. I understand that any forms or other material submitted with the application constitute part of my application for insurance. I further understand and agree that any misrepresentation or failure to provide true and accurate information may result in the voiding of and/or denial of claims under any policy issued at the option of the company. By submitting this application and any related forms to Sports & Fitness Insurance Canada, you provide Trothen & McConkey Insurance Broker Ltd. with your consent to the collection, use and disclosure of your personal information, including that previously collected, for the purpose of: communicating with you; assessing your application for insurance and underwriting your policies; evaluating claims; detecting and preventing fraud; analyzing business results; and acting as required or authorized by law. By signing this form you are agreeing and accepting all terms, limits, coverages, and exclusions contained in the quotation, which will form the basis of the policy of issuance.

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Date

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Individual Fitness Trainer Insurance Application Form

TRAINER ELIGIBILITY CHECKLIST - Please answer the following questions:

Policy Coverages and Extensions

Comprehensive Liability

Personal Injury Liability

Tenant’s Legal Liability

Coverage

Deductible

Limit

Liability - Occurrence Basis (including Professional)

Terms and Acknowledgements:

I confirm that all information above is true and accurate, and understand that the PREMIUM IS FULLY EARNED and there are no refunds once policy is bound.

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