Cryotherapy Insurance Application

CRYOTHERAPY INSURANCE APPLICATION

ACCOUNT INFORMATION

1. Name of Applicant:

Business Entity Type: LLC Partnership Joint Venture Corporation

Type of Operation: Retail Mobile Revenue-Share

Contact Name: E-mail: Phone Number:

2. Location Address (physical):

Location Address (mailing):

3. Telephone Number: Fax Number: 4. Date Established:

4. Desired Effective Date: Desired Limits of Liability: or

Desired Deductible: Do you need an excess quote? If so, what limits?

5. Gross Receipts for the Past 12 Months: $ Gross Receipts for the Next 12 Months (required): $

6. Full description of services provided:

7. Do you have any ancillary operations not stated above? Yes No If yes, provide details on last page

8. What was your total number of patient/client visits last year? Estimated next year?

9. Do you work with professional athletes and/or celebrities? Yes No If yes, provide % exposure:

10. Do you treat minors? Yes No If yes, provide % exposure:

11. Are patients/clients screened prior to use to ensure that they do not have any of the following conditions?

High Blood Pressure Yes No    Diabetes Yes No

Pregnancy Yes No    Bleeding Disorders Yes No

Uncontrolled Seizures Yes No

Cardiovascular Disease, Pacemakers or any other related cardiac issues Yes No

Severe Anemia Yes No    Claustrophobia Yes No

Acute Kidney and/or Urinary Tract Diseases Yes No

12. Are informed consent forms used in all cases prior to treatment (including minors)? Yes No If yes, please provide copies.

13. a) List the number and type of applicant's employees estimated over the next 12 months. If none, state none.

Profession (i.e. Unit Operators, NP, PA, OT, PT) Number Profession Number

b) Do you or will you use Independent Contractors: Yes No If yes, and you would like coverage for them, please attach a list including their profession.

c) Are all the above individuals licensed in accordance with applicable state and federal regulations? Yes No If no, attach explanation.

14. Do you or will you require contracted staff (if any) to carry their own Professional Liability Insurance & secure certificates of Insurance as evidence of such coverage?

Yes No If yes, at what limits? $

15. Do you require employed physicians, surgeons, nurse anesthetists, dentists, podiatrists or chiropractors to carry their own Professional Liability Insurance and secure Certificates of Insurance as evidence of such coverage?

Yes No If yes, at what limits? $ / $

16. Are all operators of the cryotherapy units required to go through training prior to operation of the unit?

Yes No If yes, please provide details of required training:

17. Do you sell, rent or otherwise provide any equipment to products or others? If yes, give details including types of products & gross receipts from each:

18. a) Do you conduct pre-employment screening and investigation? Yes No

b) Do you question prospects about previous claims or suits? Yes No

c) Are employees required to actively participate in continuing education? Yes No

d) Do you prepare job descriptions and instructional manuals for your staff? Yes No

e) Do you have a written incident/occurrence reporting policy and procedures? Yes No

19. Check all the following that apply if obtained, verified & kept on file as part of the employee hiring & screening process:

Applications Criminal Background Checks

Drug / HIV/ Hepatitis Testing Licenses Held

Education/Training/Competence Multi-State Registry

20. ATTACH DETAILED EXPLANATION FOR ANY "YES" ANSWERS:

Has the applicant or have any of the above employees:

a) Ever been the subject of disciplinary or investigative proceedings or reprimand by a governmental or administrative agency, hospital or professional association? Yes No

b) Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses? Yes No

c) Ever been treated for alcoholism or drug addiction? Yes No

d) Ever had any state professional license or license to prescribe or dispense narcotics refused, suspended, revoked, renewal refused or accepted only on special terms or ever voluntarily surrendered same? Yes No

23. Give details of Professional Liability coverage for the firm (new operations put N/A):

Carrier Limit Deductible Premium Expiration (Mo/Day/Yr)

If expiring insurance is a claims made policy, what is the retroactive date?

24. Give details of General Liability coverage for firm (new operations put N/A):

Carrier Limit Deductible Premium Expiration (Mo/Day/Yr)

If expiring insurance is a claims made policy, what is the retroactive date?

25. Has any application for Professional Liability Insurance made on behalf of the firm, any predecessors in business or present Partners ever been declined or has the insurance ever been cancelled or renewal refused?

Yes No If yes, please give details

26. Has any insurer cancelled or refused to renew any similar insurance during the past five years?

Yes No If yes, please give full details.

27. Has any claim ever been made against the firm or any of its employees?

Yes No If yes, please complete & attach claims supplement with details.

28. Is the applicant aware of any circumstances which may result in any claim against him, the firm, his predecessors in business, or any of the present or past Partners or Officers?

Yes No If yes, please give full details.

29. Who is your nitrogen supplier?

*If it is Airgas, you will be required to carry $2M/$2M underlying policy with a excess policy. Please confirm the limit requested by Airgas.

BUILDING INFORMATION:

1. Total Square Footage: Square Footage you occupy:

2. Year Building Built:

3. Any Building Updates? Roof: Wiring: Plumbing: Other:

4. Construction Type:

Frame Joisted Masonry Non-Combustible Masonry Non-Combustible Modified Fire Resistive Fire Resistive

5. How many floors in building? Which floor will you be occupying?

6. Is there an alarm system in place? Yes No Is there a Central Station alarm? Yes No

7. Does your location have sprinklers? Yes No If yes, what percentage?

8. Fire Alarm type:

9. Roof Type: Year Roof Replaced:

PROPERTY INFORMATION:

1. Number of Cryo units: Total Value of Cryo Units: $

2. Value of Computers: $

3. Value of Office Furniture $

4. Additional Property and Value:

BUSINESS INFORMATION:

1. Number of employees: Number of Part Time: Number of Full Time:

2. Estimated Annual Payroll: $ Estimated Annual Revenue: $

3. FEIN:

4. Where do you store client information (e.g., computer, cloud, file cabinet)?

5. Do you process payments online? Yes No Would you like a Cyber Liability quote? Yes No

6. Do you need an umbrella/excess quote? If so, what limit do you need?

7. How many years of management experience? Explain:

8. Do you need to list any additional insureds or loss payees on the policies? If yes, please provide the entity name, the address for the entities, and the relationship to your business:

COMMERCIAL AUTO INFORMATION (FOR MOBILE OPERATIONS ONLY):

Please provide us with a vehicle list (Make, Year, Model, VIN#), trailer information (value of trailer and identification number, if trailer is used), and a drivers list (for each driver - full name, date of birth, driver’s license number).

ADDITIONAL INFORMATION SECTION:

**Please submit a copy of your consent form/client sign off sheet along with this application.

The undersigned declares that to the best of his/her knowledge the statements herein are true. Signing of this Application does not bind the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be issued, and that this Application will be attached and become part of such Policy, if issued. Underwriters hereby are authorized to make any investigation and inquiry in connection with this Application, as they deem necessary.

Please email your completed application to: lowery.thomas@rhodesra.com