Sports & Fitness Insurance Corporation

Transcription

1 Sports & Fitness Insurance Corporation PO Box 1967 * Madison, MS * # * Fax # Dear Valued Customer: Please find the attached bond application to be completed, signed & returned to our office along with the requested supporting documents. Everything can be returned via fax or for faster processing. The cost for bonding is as follows: BOND LIMIT: COST: $ 10,000 $ 270 $ 15,000 $ 330 $ 20,000 $ 390 $ 25,000 $ 450 $ 30,000 $ 510 $ 50,000 $ 750 $ 75,000 $ 1,050 $ 100,000 $ 1,350 $ 200,000 $ 2,550 Please note that bonds are available for any limit in increments of $5,000. If the limit you need is not listed above, please contact us for pricing. Bond premiums cover a one-year term & are fully-earned/non-refundable. Should you have any questions, please do not hesitate to call. We look forward to helping you with your bonding requirements. Sincerely, Kim Tucker Kim Tucker Bond Department # , ext Fax # ktucker@sportsfitness.com

2 BOND APPLICATION INSTRUCTIONS Before your bond can be issued, you must submit all of the following items COMPLETED/SIGNED APPLICATION: Page 1: Complete, sign & date Page 2: Complete all areas indicated by an x Page 3: Sign & date Page 4: Must be signed by all owners next to Principal Page 5: Must be signed by all owners & notarized Page 6: Only applicable if more than 2 owners (all owners signatures must be notarized) Page 7: Personal financial information for each owner Page 8: Payment ADDITIONAL DOCUMENTS REQUIRED: #1: If you have been in business for 1 or more years, please submit business financials such as a balance sheets and profit & loss statement. (If new business, only personal financials are required) #2: Resume or bio for each owner. #3: A copy of the club s membership agreement which new members are required to sign. Options for submitting the required information: For immediate processing: Fax: # ktucker@sportsfitness.com - OR - Regular Mail: Fed-Ex: Sports & Fitness Insurance Sports & Fitness Insurance Attn: Bond Dept Attn: Bond Dept P.O. Box Key Drive Madison, MS Madison, MS FOR QUESTIONS, PLEASE CONTACT: Kim Tucker # ext. 2262

3 212 Key Drive, Suite A Madison, MS P.O. Box 1967 Madison, MS Bond Application ENTIRE form MUST be completed for bond approval. ASSOCIATION INFORMATION Official Business Name EXACTLY as it is registered with your State: Phone: Toll Free: Fax: Corporation Partnership Proprietorship Individual (or Husband & Wife) LLC Location Address: Mailing Address: : Address: Contact Person: Fax No. : Years in business: Renewal? Prior Bond Number City: County: State: Zip: City: County: State: Zip: SURETY BOND INFORMATION (Please answer ALL questions) Name of Bank: Address of Bank: 1. Is there currently a bond in place? No Yes, with whom What is the current rate being charged? 2. What is your club s initial membership fee? 3. What is the duration of your membership? Phone No. (of club): Phone No. (other): Desired Effective Date: Phone No. of Bank: 4. Does your club require members to pay dues in advance? Yes No If yes, please describe: 5. Do you offer any services outside of basic health club services? Yes No If yes, please explain: 6. Who currently writes your liability insurance? Name of Insurance Company: Name of Agent: Personal information about you may be obtained from persons other than you. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instruction on how to submit a request to us. Any person who knowingly and with intent to defraud any insurance company or another person, files an application 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 and subjects this person to criminal and civil penalties. / / Producer s Signature (if any) Signature of Applicant Date Title Bond Application v /15/12 Page 1 of 8

4 ACE Companies Bond Application ** Please complete ALL areas indicated by "x". Page 2 of 8

5 ACE Companies Bond Application Page 3 of 8

6 ACE Companies Bond Application Page 4 of 8

7 SHTFRMINCORP72393 BS b Page 5 of 8

8 FOR NOTARIAL ACKNOWLEDGEMENT OF PRINCIPAL/INDEMNITOR'S SIGNATURE CORPORATE ACKNOWLEDGMENT Page 6 of 8

9 Personal Financial Information Names: Personal Financial Information As of the following date: Page 7 of 8

10 SURETY BOND PAYMENT OPTIONS If you wish to pay your bond with a credit card*, please complete the following: Card holders name: Credit card number: Expiration date: / Amount: Signature: *We accept Visa, Master Card & Discover (*No American Express) If you wish to pay your bond with a checking account, please complete the following: Account holders name: Bank name: Routing number (9 digits): - - Account number: Amount: Signature: Fax the completed form back to , or scan & to: ktucker@sportsfitness.com Page 8 of 8