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Dba Fitness Insurance Agency in MI, TX, NY, NC and CA. CA License Number 0G00756. HEALTH CLUB INCIDENT REPORT (TO BE COMPLETED BY ACTING MANAGER) TODAY S DATE: DATE OF INCIDENT: TIME OF INCIDENT: AM/PM Name of Club: Address: Phone #: Contact Person Name & Phone #: Name /Job Description of Person Completing this Form: ABOUT THE INJURED PERSON Name of Injured Person: Age: Sex: Male/Female How long has this person been a member? Address: Home Phone: Work Phone:.

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