CPMS Insurance Application Form

CPMS Insurance Application Form

Insurance application for Pilates Professionals for the CPMS Insurance Solution.
Personal & Business Information
Name

First NameLast Name
Business Name
Business Address

Street Address

Street Address Line 2
CityProvincePostal Code
Is the mailing address different from the business address?
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Business Structure / Legal Entity
CPMS Individual Login Email
example@example.com
CPMS Business Login Email
example@example.com
Pilate Certifications
Pilates Designation
Services Offered
Services offered
Pilates modalities used

Other
Other modalities used

Other
Specialized services

Other
Diagnostic or screening procedures

Other
Additional details about services, modalities, or exclusions
Session Volume
Average weekly Classes taught
Average weekly Private Sessions facilitated
Risk Management & Compliance Procedures
Do you have written risk management policies and procedures?
Are incident reporting procedures documented?
How are incident reports reviewed and escalated?
Are participant consent procedures documented in writing?
How are participant consents obtained and recorded?
Describe any additional risk management or compliance measures in place.
Insurance History & Claims
Previous insurance carrier name
Previous policy start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous policy end date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Number of claims in the past 5 years
Claim details and loss descriptions
Prior cancellations, refusals, or non-renewals explanation
Coverage Tier Selection
Coverage Tier Selection
Per-Claim Limit
Aggregate Limit
Optional Coverage Enhancements

Other
Higher-Tier Coverage Preference

Other
Employees Insured
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Further Staff Information
Contractors and their Policies
Name

First NameLast Name
Policy Number
Name

First NameLast Name
Policy Number
Name

First NameLast Name
Policy Number
Name

First NameLast Name
Policy Number
Relationship to applicant
Name

First NameLast Name
Requested wording or special instructions
Declarations & Signature
Name of Declarant

First NameMiddle NameLast Name
Title / Position
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

CPMS Insurance Application Form

Personal & Business Information

Services Offered

Session Volume

Risk Management & Compliance Procedures

Insurance History & Claims

Coverage Tier Selection

Employees Insured

Contractors and their Policies

Declarations & Signature