* = required field

Name of Applicant*
Email*	Fax 999-999-9999
Street Address*
City*	State          AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip Code
Phone*	999-999-9999
Are you Accredited by ACE, ACSM, NASM, NSCA, NCSF, NFPT, NESTA, and/or IFPA?*	... Yes No
Check all Accredited Certificate(s) that you have.*	ACE   ACSM   NASM   NSCA   NCSF   NFPT   NESTA   IFPA (Please fax a copy of your certificate(s) to (630)393-5666 or email them to info@dhcins.com after you submit this application.) ++Please note that we can only accept licenses from the listed accredited personal training certifications.  Any other certifications will need to use the non-certified rate.
Years of Accredited Experience*	Are you 18 or older?          ... Yes No
Effective Date of Coverage*
Description of Instructor Activities*
Estimated Number of Clients*
Location(s) of Training*
Does the Facility carry Liability Insurance?*	... Yes No   Limits

 

Type of Instructor (check all that apply):

Aerobics	Cardio Kickboxing	Dancercise	Personal Trainng	Strength
Pilates	Aquatic Exercise	Tai Chi	Fitness Bootcamp	Children's Fitness Programs
Yoga	Stroller Strides	Gyrotonic	Other
Tae Bo	Exercise	Spinning

 

List any Additional Insured Names, Addresses and Relationship to the applicant:

 

Premium Rates and Benefits (Please check all plan numbers that apply.)

$1,000,000.00 Per Occurrence / $1,000,000.00 Aggregate
1. Program Rate with Accredited Certification++	$100.00
2. Program Rate without Accredited Certification++	$200.00
3. Premium cost to increase the general aggregate           to $2,000,000.00	Additional 5% of total Premium
++ Please note that we can only accept licenses from the listed accredited personal training certifications.  Any other certifications will need to use the non-certified rate.