INDICATE SECTIONS ATTACHED LOC # BLD # STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITS INTEREST YR BUILT PART OCCUPIED

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1 ACORD TM COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION AGENCY NAIC CODE: UNDERWRITER FAX (A/C, No.): POLICIES OR PROGRAM REQUESTED DATE (MM/DD/YYYY) UNDERWRITER OFF. CODE: AGENCY CUSTOMER ID: STATUS OF TRANSACTION SUB CODE: INDICATE SECTIONS ATTACHED BOUND (Give Date and/or Attach Copy): PROPOSED EFF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN AUDIT CHANGE DATE TIME AM DIRECT BILL NAME (First Named Insured & Other Named Insureds) FEIN OR SOC SEC # (of First Named Insured): EQUIPMENT FLOATER GARAGE AND DEALERS PROPERTY INSTALLATION/BUILDERS RISK VEHICLE SCHEDULE GLASS AND SIGN ELECTRONIC DATA PROC BOILER & MACHINERY ACCOUNTS RECEIVABLE/ VALUABLE PAPERS COMMERCIAL GENERAL LIABILITY WORKERS COMPENSATION CRIME/MISCELLANEOUS CRIME BUSINESS AUTO UMBRELLA TRANSPORTATION/ MOTOR TRUCK CARGO TRUCKERS/MOTOR QUOTE ISSUE RENEW ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES. CANCEL PM AGENCY BILL APPLICANT INFORMATION PACKAGE INFORMATION MAILING ADDRESS INCL ZIP+4 (of First Named Insured) ADDRESS(ES): INDIVIDUAL CORPORATION SUBCHAPTER "S" CORPORATION LIMITED LIAB CORP PARTNERSHIP JOINT VENTURE NOT FOR PROFIT ORG NO. OF MEMBERS AND MANAGERS INSPECTION CONTACT WEBSITE ADDRESS(ES): CR BUREAU ID NUMBER NAME ACCOUNTING RECORDS CONTACT DATE BUS STARTED PREMISES INFORMATION LOC # BLD # STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITS INTEREST YR BUILT PART OCCUPIED INSIDE OUTSIDE OWNER TENANT INSIDE OUTSIDE OWNER TENANT INSIDE OUTSIDE OWNER TENANT NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S) GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES YES NO EXPLAIN ALL "YES" RESPONSES 1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY? 7. ANY PAST ES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? 1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES? 8. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? (In RI, this question must be answered by any applicant for property insurance. 3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 4. ANY CATASTROPHE EXPOSURE? 9. ANY UNCORRECTED FIRE CODE VIOLATIONS? 5. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? 10. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST 5 YEARS? 6. ANY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED 11. HAS BUSINESS BEEN PLACED IN A TRUST? DURING THE PRIOR 3 YEARS? (Not applicable in MO) IF YES, NAME OF TRUST: /PROCESSING INSTRUCTIONS YES NO ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied) APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER ACORD 125 (2002/01) PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1993

2 PRIOR INFORMATION LINE CATEGORY G E N C E O R M A M L E L R I C A I B A I L L IT Y TYPE RETRO DATE GENERAL AGGREGATE PRODUCTS COMP OP AGGREGATE PERSONAL & ADV INJ EACH L I FIRE DAMAGE M I MEDICAL EXPENSE T S BODILY INJURY AGGREGATE PROPERTY DAMAGE AGGREGATE CLAIMS CLAIMS CLAIMS CLAIMS CLAIMS MADE MADE MADE MADE MADE A U L T I O A M B O I B L I I L T E Y P R O P E R T Y COMBINED SINGLE LIMIT TYPE COMBINED SINGLE LIMIT BODILY INJURY EA PERSON EA ACCIDENT PROPERTY DAMAGE TYPE BUILDING PERS PROP TYPE LIMIT HISTORY AMT AMT ENTER ALL CLAIMS OR ES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR S THAT MAY GIVE RISE TO CLAIMS FOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY) CHK HERE IF NONE SEE ATTACHED SUMMARY DATE OF DATE AMOUNT AMOUNT CLAIM LINE TYPE/DESCRIPTION OF OR CLAIM OF CLAIM PAID RESERVED STATUS OPEN CLOSED OPEN NOTE: FIDELITY REQUIRES A FIVE YEAR HISTORY ATTACHMENTS CLOSED STATE SUPPLEMENT(S) (If applicable) COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state's requirements.) NOTICE OF INSURANCE INFORMATION PRACTICES PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT RENEWALS. 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. 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. ACORD 125 (2002/01)

3 ACORD PRODUCER TM COMMERCIAL GENERAL LIABILITY SECTION APPLICANT (First Named Insured) DATE CODE: AGENCY CUSTOMER ID: COVERAGES SUB CODE: PER CLAIM PER EFFECTIVE DATE EXPIRATION DATE DIRECT BILL PAYMENT PLAN AUDIT FOR COMPANY USE ONLY COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE $ PREMIUMS CLAIMS MADE PRODUCTS & COMPLETED OPERATIONS AGGREGATE $ OWNER'S & CONTRACTOR'S PROTECTIVE PERSONAL & ADVERTISING INJURY $ EACH $ DEDUCTIBLES DAMAGE TO RENTED PREMISES (each occurrence) $ PROPERTY DAMAGE BODILY INJURY $ $ $ LIMITS MEDICAL EXPENSE (Any one person) $ EMPLOYEE BENEFITS $ AGENCY BILL OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the Business Auto Section, ACORD 127) PREMISES/OPERATIONS PRODUCTS OTHER TOTAL SCHEDULE OF HAZARDS LOCATION CLASS PREMIUM CLASSIFICATION # CODE BASIS EXPOSURE TERR RATE PREMIUM PREM/OPS PRODUCTS PREM/OPS PRODUCTS RATING AND PREMIUM BASIS (P) PAYROLL - PER $1,000/PAY (C) TOTAL COST - PER $1,000/COST (U) UNIT - PER UNIT (S) GROSS SALES - PER $1,000/SALES (A) AREA - PER 1,000/SQ FT (M) ADMISSIONS - PER 1,000/ADM (T) OTHER CLAIMS MADE (Explain all "Yes" responses) 1. PROPOSED RETROACTIVE DATE: 1. DEDUCTIBLE PER CLAIM: $ 2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COV: 2. NUMBER OF EMPLOYEES: 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION YES NO BEEN EXCLUDED, UNINSURED OR SELF-INSURED 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: FROM ANY PREVIOUS COVERAGE? 4. RETROACTIVE DATE: 4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS? EMPLOYEE BENEFITS LIABILITY ACORD 126 (2000/04) PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1993

4 CONTRACTORS EXPLAIN ALL "YES" RESPONSES (For past or present operations) YES NO EXPLAIN ALL "YES" RESPONSES (For past or present operations) YES NO 1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS FOR OTHERS? LESS THAN YOURS? 2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT EXPLOSIVE MATERIAL? PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? 3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR UNDERGROUND WORK OR EARTH MOVING? WITHOUT OPERATORS? /DESCRIBE THE TYPE OF WORK SUBCONTRACTED $ PAID TO SUB- % OF WORK # FULL- # PART- CONTRACTORS: SUBCONTRACTED: TIME STAFF: TIME STAFF: PRODUCTS/COMPLETED OPERATIONS TIME IN EXPECTED PRODUCTS ANNUAL GROSS SALES # OF UNITS MARKET LIFE INTENDED USE PRINCIPAL COMPONENTS EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation) YES NO EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation) YES NO 1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS? 6. PRODUCTS RECALLED, DISCONTINUED, CHANGED? 2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? 7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER 3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW APPLICANT LABEL? PRODUCTS PLANNED? 8. PRODUCTS UNDER LABEL OF OTHERS? 4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS? 9. VENDORS COVERAGE REQUIRED? 5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY? 10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS? PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC ADDITIONAL INTEREST/CERTIFICATE RECIPIENT INTEREST RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER ADDITIONAL INSURED LOCATION: BUILDING: VEHICLE: BOAT: MORT LIENHOLDER EMPLOYEE AS LESSOR GENERAL INFORMATION ITEM DESCRIPTION: SCHEDULED ITEM NUMBER: EXPLAIN ALL "YES" RESPONSES (For all past or present operations) YES NO EXPLAIN ALL "YES" RESPONSES (For all past or present operations) YES NO 1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? OTHER 12. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? 13. ANY DEMOLITION EXPOSURE CONTEMPLATED? 2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? 14. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN 3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS JOINT VENTURES? INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? 15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? (e.g. landfills, wastes, fuel tanks, etc) 4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST 5 YEARS? ACORD 45 attached for additional names 16. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? 17. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? 5. MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS? 18. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? YOUR PREMISES WITHIN THE LAST THREE YEARS? 7. ANY PARKING FACILITIES OWNED/RENTED? 19. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY 8. IS A FEE CHARGED FOR PARKING? IN EFFECT? 9. RECREATION FACILITIES PROVIDED? 20. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE 10. IS THERE A SWIMMING POOL ON THE PREMISES? ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY 11. SPORTING OR SOCIAL EVENTS SPONSORED? OF THE PREMISES? ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR; IN DC, LA, ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED) ACORD 126 (2000/04) ATTACH TO APPLICANT INFORMATION SECTION

5 ACORD TM PROPERTY SECTION PRODUCER APPLICANT FAX (First (A/C, No): Named Insured) DATE (MM/DD/YYYY) EFFECTIVE DATE EXPIRATION DATE DIRECT BILL PAYMENT PLAN AUDIT AGENCY BILL CODE: SUB CODE: FOR COMPANY USE ONLY AGENCY CUSTOMER ID: PREMISES INFORMATION PREMISES #: BUILDING #: STREET ADDRESS: SUBJECT OF INSURANCE AMOUNT COINS % VALUATION CAUSES OF INFLATION GUARD % DEDUCTIBLE BLANKET COVERAGE FORMS AND CONDITIONS TO APPLY ADDITIONAL INFORMATION - BUSINESS INCOME/EXTRA EXPENSE BUSINESS INCOME W/O EXTRA EXPENSE EXTRA EXPENSE TYPE OF BUSINESS ORDINARY PAYROLL POWER/HEAT EXT PERIOD TUITION FEES OFF PREM POWER DEPEND PROP NON MFG EXCL INCL $ DED DAYS $ STUDENTS POWER % COIN MFG 90 DAYS ELEC MEDIA MO PERIOD $ OTHER ED WATER CONT LOC SERV/INC MINING 180 DAYS DAYS LIMIT COMM REC LOC (DESCR BELOW) % COINS $ ORD OR LAW MAX PERIOD MFG LOC NAME AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROP DAYS ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION EXTRA EXPENSE LIMIT PAY LDR LOC (DESC BELOW) DAYS PERIOD REST % % % % CONSTRUCTION TYPE DISTANCE TO FIRE DISTRICT/CODE NUMBER PROT CL # STORIES # BASM'TS YR BUILT TOTAL AREA HYDRANT FIRE STAT BUILDING IMPROVEMENTS WIRING, YR: FT PLUMBING, YR: MI BLDG CODE TAX CODE ROOF TYPE OTHER OCCUPANCIES GRADE ROOFING, YR: HEATING, YR: WIND CLASS HEATING BOILER ON PREMISES? YES NO SEMI- OTHER: RESISTIVE RESISTIVE OTHER IF YES, IS INSURANCE PLACED ELSEWHERE? YES NO RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCE BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE EXTENT GRADE BURGLAR ALARM INSTALLED AND SERVICED BY # GUARDS/WATCHMEN WITH KEYS CLOCK HOURLY PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems) % SPRNK FIRE ALARM MANUFACTURER LOCAL GONG ADDITIONAL INTERESTS RANK: NAME AND ADDRESS EVIDENCE RANK: NAME AND ADDRESS EVIDENCE INTEREST ICATE INTEREST ICATE VALUE REPORTING INFORMATION REPORTING FORM: PROVIDE AVERAGE VALUES FOR PAST 12 MONTHS PREMISES/ ANY OTHER LOCA- ANY OTHER LOCA- PREMISES NOT OWNED TION DECLARED TION ACQUIRED OR ACQUIRED SUBJECT OF INSURANCE BUILDING AT INCEPTION AFTER INCEPTION LIMIT ACORD 140 (2001/08) ATTACH TO APPLICANT INFORMATION SECTION ACORD CORPORATION 1985

6 PREMISES INFORMATION PREMISES #: BUILDING #: STREET ADDRESS: INFLATION BLANKET SUBJECT OF INSURANCE AMOUNT COINS % VALUATION CAUSES OF GUARD % DEDUCTIBLE COVERAGE FORMS AND CONDITIONS TO APPLY ADDITIONAL INFORMATION - BUSINESS INCOME/EXTRA EXPENSE BUSINESS INCOME W/O EXTRA EXPENSE EXTRA EXPENSE TYPE OF BUSINESS ORDINARY PAYROLL POWER/HEAT EXT PERIOD TUITION FEES OFF PREM POWER DEPEND PROP NON MFG EXCL INCL $ DED DAYS $ STUDENTS POWER % COIN MFG 90 DAYS ELEC MEDIA MO PERIOD $ OTHER ED WATER CONT LOC SERV/INC MINING 180 DAYS DAYS LIMIT COMM REC LOC (DESCR BELOW) % COINS $ ORD OR LAW MAX PERIOD MFG LOC NAME AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROP DAYS ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION EXTRA EXPENSE LIMIT PAY LDR LOC (DESC BELOW) DAYS PERIOD REST % % % % CONSTRUCTION TYPE DISTANCE TO FIRE DISTRICT/CODE NUMBER PROT CL # STORIES # BASM'TS YR BUILT TOTAL AREA HYDRANT FIRE STAT BUILDING IMPROVEMENTS WIRING, YR: FT PLUMBING, YR: MI BLDG CODE TAX CODE ROOF TYPE OTHER OCCUPANCIES GRADE ROOFING, YR: HEATING, YR: WIND CLASS HEATING BOILER ON PREMISES? YES NO SEMI- OTHER: RESISTIVE RESISTIVE OTHER IF YES, IS INSURANCE PLACED ELSEWHERE? YES NO RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCE BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE EXTENT GRADE BURGLAR ALARM INSTALLED AND SERVICED BY # GUARDS/WATCHMEN WITH KEYS CLOCK HOURLY PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO/Chemical 2 Systems) % SPRNK FIRE ALARM MANUFACTURER LOCAL GONG ADDITIONAL INTERESTS RANK: NAME AND ADDRESS EVIDENCE RANK: NAME AND ADDRESS EVIDENCE INTEREST ICATE INTEREST ICATE VALUE REPORTING INFORMATION REPORTING FORM: PROVIDE AVERAGE VALUES FOR PAST 12 MONTHS PREMISES/ ANY OTHER LOCA- ANY OTHER LOCA- PREMISES NOT OWNED TION DECLARED TION ACQUIRED OR ACQUIRED SUBJECT OF INSURANCE BUILDING AT INCEPTION AFTER INCEPTION LIMIT ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR or VT; In DC, LA, ME and VA, insurance benefits may also be denied) ACORD 140 (2001/08)

7 Martial Arts Programs Application (Complete in addition to ACORD General Liability Application) Name of Applicant: 1. Type of school: Amateur Professional Semi-professional Martial art taught: 2. Annual gross receipts from all operations: (include tuition fees, food receipts, cl othing and equipment sales, etc. ) 3. Describe other operations on premises (weight room, exercise equipment, boxing ring, heavy bags, tanning beds, pool, showers, locker room, climbing wall, etc.) 4. Describe protective equipment (mats, pads, glov es, headgear, etc.), if any, that is used: 5. Are students or their parents required to sign liability waivers? If so, please attach a copy of the waiver wording that is used. 6. Describe any tournaments you sponsor. (A tournament for this purpose is an event sponsored by you, open to the public, where the participants are members of the club or school competing with members from another club or school.) Yes No 7. Describe any exhibitions you sponsor. (An exhibition for this purpose is an event sponsored by you, open to the public, where the participants are limited to members of the school or club.) 8. Describe any additional off-site activities: 9. Total number of students enrolled: 10. Students ages range from to Are you involved with any Ultimate Fighting Championships? Yes No APPLICABLE IN THE STATE OF NEW YORK 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. FRAUD WARNING 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. PRODUCER S SIGNATURE: DATE: APPLICANT S SIGNATURE: DATE: AGENT NAME: AGENT LICENSE NUMBER: (Applicable to Florida Agents Only.) WHI-APP-116 (8-02) Page 1 of 1