License No. OE14627
Nexo General Information Application:
CrossFit Affiliate and CrossFit Home-Based Affiliate
Office # 310-937-2007
Submit Completed Application to ereingen@nexoins.com or fax to 310-937-1127
TO AVOID A PROCESSING DELAY, COMPLETE ALL SECTIONS AND SIGN
WHERE REQUIRED.
Named Insured
(including dba, if any):
The Named Insured is
applying for which types
of insurance coverages
(mark all that apply)?
Contact Person:
Phone Number:
Fax Number:
Email Address:
Type of Entity:
FEIN/SSN:
Description of
operations:
Date Business Started:
Projected Annual Gross
Revenue/Receipts:
Total Number of Current
Members/Clients:
Total Payroll:
Number of employees:
Number of Independent
Contractors:
Affiliate Website:
Proposed Effective Date:
General Liability ____
Property ____
Professional Liability Insurance ____
Employment Practices Liability Insurance ____
Workers Compensation Insurance _____
Occupational Accident Ins. For Independent Contractors ____
Corporation____ LLC ____ Partnership___ Individual____
CrossFit licensed affiliate with a permanent leased location___
Home-Based CrossFit licensed affiliate______
$
$
Mailing Address:
If applicant is a home-based affiliate please proceed to “Previous Insurance Carrier” section.
Location Address (if different from
mailing address):
Are you the Tenant or Owner at your operating location?
____ Tenant
____ Owner
Total Square Footage Occupied:
Year the building was Built:
County of your operating location:
Hours of Operation:
What is the cost to replace all of your business property, including:
$
Supplies, equipment, inventory, contents, signage and any items that you
have installed or altered at the premises at your expense ( flooring,
lighting, or any other improvements)? This will establish the Business
Personal Property Coverage Limit.
Previous Insurance Carrier:
Policy Number:
Total Premium:
Expiration date:
Losses (describe in detail):
CrossFit, Inc. and CrossFit Kids, Inc. (if applicable) will automatically be named as
Additional Insureds on your policy. If you are required to provide a Certificate of
Insurance naming any other entity as Additional Insured (such as the owner of a
leased premises), provide the information below:
Additional Insured #1
Entity Name:
Mailing Address:
City, ST, Zip
Relationship to you:
Additional Insured #2
Entity Name:
Mailing Address:
City, ST, Zip
Relationship to you:
General Information Questions:
Please explain “Yes” answers thoroughly in the Additional Comments section.
Yes or No
Are Athletic Teams Sponsored, other than for CrossFit Games?
Is the affiliate a member of the CrossFit Risk Retention Group?
Are Sub Contractors, including Independent Contractor trainers, allowed to
work without providing a certificate of insurance?
During the last five years (ten in Rhode Island), has any applicant been indicted
for or convicted or any degree of the crime of Fraud, Bribery, Arson, or any other
arson-related crime in connection with this or any other property?
Has any policy or coverage been declined, cancelled or non-renewed during the
prior 3 years?
Do you lease employees to or from other employers?
Any Workers Compensation Carried?
Does the entity that will operate the CrossFit affiliate own or operate another
business? If yes, provide details in Comments area.
Any other insurance with this company? (List Policy Numbers)
Are you involved in manufacturing, mixing, relabeling or repackaging of
products?
Do you rent or loan equipment to others?
Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien
during the past five (5) years?
Any exposure to flammables, explosives or chemicals?
Any catastrophe exposure?
Any past losses or claims relating to sexual abuse or molestation allegations,
discrimination or negligent hiring?
Any uncorrected fire code violations?
Supplemental Underwriting Questions:
Yes or No
Does the affiliate conduct training with children under the age of 18?
If yes, is the affiliate licensed to conduct CrossFit Kids activities?
Does any fighting sport instruction, training or competition take place at the
affiliate location?
Does affiliate offer any Parkour training or instruction?
Does the affiliate offer or sell any food products? If so, what are the annual
gross receipts collected from food products?
$
Does the affiliate location offer any services or fitness training that is not
CrossFit certified? Examples include: Yoga classes, massage services, selfdefense instruction, training programs/seminars or selling products
unrelated to the CrossFit affiliate operations. If yes, list and provide a
detailed explanation below:
Does the operating location include or offer the following? Please answer “yes” or “no”.
Tanning:
If yes, number of units:
Steam Room:
If yes, number of units:
Jacuzzi/Spa:
If yes, number of units:
Sauna:
If yes, number of units:
Courts:
If yes, number of units:
Pools:
If yes, number of units:
Climbing Wall:
If yes, number of units:
Childcare area:
Additional
Comments:
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 POLICY 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 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 INSTRUCTIONS 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 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, FL, HI, MA, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied) IN
FLORIDA, 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. THE UNDERSIGNED IS AN
AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS
BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT
THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
Applicant Signature: ________________________________Date:_____________________
Printed Name: _____________________________________
For Nexo Office Use:
CrossFit RRG Shareholder:_____
CrossFit RRG Insured: _____
Ind. Cont. Coverage verified for Non-CF RRG Insured: _____