LIO Fitness Studio Application

1. Producer & Submission Info

Brokerage / Agency

Producer / Broker Name

Producer Email

Producer Phone

Desired Effective Date *

Expiration Date *

Tax Status *

For-Profit Non-Profit

2. Named Insured

Named Insured (Legal Name)

DBA / Studio Name

Primary Contact

Phone

Email Address

Website

Mailing Address

Street Address

Street Address 2

City

State

Zip Code

3. Studio Location

Enter the primary studio location where classes/training operate. If same as mailing address, check below. Add additional locations in Section 8.

Same as mailing address

Street Address

City

State

Zip Code

Total Square Footage

Occupancy

Owned Leased

Hours of Operation

4. Coverage Requested

Lines of Coverage

General Liability (includes Professional Liability sublimit for instructors/trainers) Abuse & Molestation Liability Hired & Non-Owned Auto Liability Commercial Property Inland Marine (equipment) Excess Liability

5. Studio Profile & Modality

Studio Classification

ⓘ Select the primary modality that best describes the studio's dominant programming. If the studio offers more than one format, classify by the predominant programming.

Primary Studio Type

If Other, Describe

Secondary Modalities Offered

Franchise Affiliation

Is this studio part of a franchise system?

Yes No – Independent

Membership & Class Participation

ⓘ Enter the total member count below and other applicable exposure data.

Total Annual Members *

Total Members Under 18 Years Old

Avg. Class Size

Avg. Classes Per Week (per studio)

Avg. Cost Per Class ($)

Avg. Class Attendance Per Member / Week

Revenue Composition

ⓘ Disclose all revenue sources accurately.

Revenue Source	Annual Revenue ($)	% of Total
Class / Membership Fees
Personal Training Sessions
Retail / Apparel Sales
Nutritional Supplements / Private Label
Food / Smoothie Bar
Other Ancillary Services
TOTAL ANNUAL REVENUE

6. Operations & Risk Controls

Organizational Background

Years in Operation *

Year Business Was Established

Years Owner/Director Experience

Instructors & Staffing

# Full-Time Instructors / Trainers

# Part-Time Instructors / Trainers

# Independent Contractor Instructors

# Admin / Front Desk Staff

Are all instructors / trainers certified by a nationally recognized organization (e.g., NASM, ACE, ACSM, NSCA, AFAA, Yoga Alliance, RYT, modality-specific cert)?

Yes Partially No

Are instructor certifications and CPR/AED training documented and tracked?

Yes No

Do independent contractor instructors carry their own liability insurance?

Yes No N/A – None used

Facility & Equipment

Is the studio in a defined, dedicated physical location (no in-home / garage / public-space training)?

Yes No

Does the studio operate 24-hour / unstaffed access?

Yes No

Are all equipment items inspected on a regular schedule and maintained per manufacturer guidelines?

Yes No

Is there a documented cleaning / sanitation protocol between classes?

Yes No

Are AED, first aid kit, and emergency response procedures in place on-site?

Yes No

Programming & Participant Onboarding

Are all members required to sign a waiver / release before participating?

Yes No

Are members required to complete a health questionnaire (PAR-Q or similar) before training?

Yes No

Is there a structured new-member intake / orientation (form check, equipment use, modifications)?

Yes No

For minors under 18, are waivers signed by a parent or legal guardian?

Yes No N/A – No minors

Ancillary Operations

Does the studio sell or serve alcohol at any events or on-premises?

Yes No

Does the studio sell nutritional supplements or private-label merchandise?

Yes No

Does the studio offer incidental childcare (e.g. kids' room while members work out)?

Yes No

Does the studio offer hot yoga for clients under age 16?

Yes No N/A – No hot yoga

Does the studio offer training in private homes, garages, or public spaces (parks, beaches, etc.)?

Yes No

Does the studio offer paddleboard yoga, fitness on water, or any aquatic-based programming?

Yes No

Is an Additional Insured endorsement required (e.g., landlord, franchisor)?

Yes No

Additional Insured Name & Description (if yes, please complete the below)

7. Underwriting Supplemental

Prior Insurance

Current / Prior Carrier

Prior Policy Expiration Date

Prior Annual Premium

A. General

B. Waivers & Member Releases N/A

C. Instructor Credentials & Safety Standards N/A

D. Abuse & Molestation Controls N/A

E. Property & Equipment (if Property requested) N/A

F. Ineligible Exposures Declaration

The applicant must review the following ineligible operations and confirm none apply.

Ineligible Facility Types

Large Commercial "Box Gyms"
24-Hour / Unstaffed Gyms
Membership-Only Gyms (LA Fitness, Lifetime)
Trampoline / Rebound Facilities
Rock Climbing Gyms / Walls
Arcades / Family Entertainment
Bowling Alleys
MMA / Boxing Gyms / Fight Clubs
Sparring / Combat / Weapons
Pole Dancing Studios
Bungee Fitness Studios
Gymnastics Training Centers
Cryotherapy Studios
Contrast Therapy Studios
Recovery Studios
In-Home / In-Home Training
Self-Defense for LE / Military
Float Tanks / Sensory Dep.
Oxygen Deprivation Training
Pools w/ Diving >3m, Hot Tubs, Saunas
Stadiums >5,000 Seats
Facilities w/ Full Bar/Restaurant (>25% Rev)
SCUBA Training Facilities
Physical Therapy Centers

Ineligible Programming & Ancillary

Boxing / MMA / Combat Sports
Gymnastics Training / Competition
Wrestling (unsanctioned)
Yoga w/ Animals
Acro-Yoga
Paddleboard Yoga
Hot Yoga (Under Age 16)
Fitness on Water
Aerial / Stunting / Acrobatics
Day Spas
Beauty / Hair Salons
Tanning Salons (incl. Spray)
Massage
Tattoo Parlors
BYO Alcohol Events
Studios w/o Defined Location

I confirm that the applicant does not operate or have any involvement with any of the ineligible facility types or programming listed above.

8. Additional Locations / Named Insureds

Complete if studio operates multiple physical locations or requires additional named insured entities. Attach a schedule if more than two.

#	Location / Entity Name	Address (Street, City, State, Zip)	Sq. Ft.	# Members
1
2
3
4

9. Supporting Documents

Please send the following along with this completed application back to your underwriter. Loss runs are required — everything else is greatly appreciated if you have it available at this time. The more we have upfront, the smoother the process!

Required

4-year loss runs dated within 3 months of the proposed effective date

Also Appreciated — Please Include Any of the Following if Available

Sample member waiver / release form & PAR-Q health questionnaire
Class schedule and list of modalities offered
Instructor roster with certifications (CPR/AED and modality-specific)
Background check policy (if Abuse & Molestation coverage is requested)
Lease / occupancy agreement (if requesting Property)
SOV / Statement of Values (if Property is requested)
Franchise agreement summary (if applicable)
Sample emergency action plan
ACORD 125 & 126 / GL supplement

Additional Notes for Underwriter

10. Fraud Warning & Declaration

⚠ NOTICE TO POLICYHOLDERS — FRAUD NOTICE (NTC FR01 10/21)

NOTICE TO APPLICANTS: 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 act, which is a crime, and may subject such person to criminal and civil penalties.

NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND, AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO CALIFORNIA APPLICANTS: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO KANSAS APPLICANTS: Any person who knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance that such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK APPLICANTS: 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 is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

FIRE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON APPLICANTS: 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, may be guilty of a fraudulent act, which may be a crime, and may subject such person to criminal and civil penalties.

NOTICE TO PENNSYLVANIA APPLICANTS: 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 is a crime and subjects such person to criminal and civil penalties.

NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE. The undersigned authorized representative affirms that all information provided is accurate and complete to the best of their knowledge. I understand that coverage is not bound until confirmed in writing by LIO Insurance.

11. Signatures

Applicant / Authorized Representative

Applicant / Authorized Representative Name

Title

Applicant Signature

Signature

Date

Producer / Broker

Producer Name

License Number

Producer Signature

Signature

Date