ANYTIME FITNESS FRANCHISE DISCLOSURE DOCUMENT

INSURANCE AUTHORIZATION
(FOR NON-TITLED EQUIPMEN'I)
TO;
AGEN'r: _________________ PHONE:
INSURER: POLlCY#: ____ _
ADDRESS: EXPIRES: ____ _
CITY: STATE: ZIP CODE .... : ____ _
VALUE OF EQUIPMENT/COLLATERAL TO BE COVERED BY INSURANCE:
FROM:
LESSEEIDEBTOR:
123 LANE
SCOTTSDALE, AZ 85260 312-555-1234
Phone Fax
Equipment/Collateral Description: FITNESS
The equipment/collateral is 123 LANE
locmedm: -----------------------------------------------
SCOTTSDALE MARlCOPA AZ 85260
Property Coverage (ACORD 28 or equivalent): Property coverage is to be provided for the full value of the
equipment. LEAF Funding, Inc. and/or its assignees is to be named as Loss Payee using a Lender's Loss Payable
endorsement using ISO Fonn BP1203, CP1218 or its equivalent.
Liability (ACORD 25 or equivalent); Coverage should be written within minimum limits of $300,000 each
occurrence and $600,000 general aggregme. LEAF Funding, Inc. and/or its successors, assignors and assignees are
to be named as Additional Insured using ISO Fonn BP4016, CG2028 or its equivalent.
We have entered into a lease agreement, finance agreement, or note and security agreement and have agreed to be
responsible for insuring the equipment as described above.
Please see thm we have immediate coverage and provide verification of such coverage in the form of a copy of the
Insurance Policy or a Certificate of Insurance with a 10 day notice of cancellation clause to LEAF Funding, Inc. in
care of American Lease Insurance, 654 Amherst Rd., Ste. 307, Sunderland, MA 01375.
Thank You,
JOHN DOE PRESIDENT
Signature Print Name Title Date
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