Click Here to download a printable application
Please Note: How you enter your name is EXACTLY how it will appear on your certificate of insurance
*All items marked with an asterisk are required fields.
Effective Date:
* My Name is:
* Street Address:
* City:
* State:
Select one...
AL AK AZ AR AS CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY
* Zip Code: (5 digits only)
* Email:
* Re-enter Email:
* Contact Phone (no dashes or spaces) :
License Number:
Choose Your Profession:
Please make a selection
Massage
Aroma Therapy
Esthetics
Cosmetology
Breathing work
Asian Bodywork
Colonic Education
Movement
Lymphology
Teaching of Dance
Kinesiology
Reflexology
Nail Tech
Yoga
Feng Shui
Reiki
Spiritual Touch
Animal Massage
Please Select Other Disciplines You Practice: (select all that apply)
Insurance Plus membership will be effective upon the completion of this application.
Additional Insured Option
Additional Insured - An individual or entity, other than the named insured, that is added as an insured and protected under the named insured's policy. Additional insureds are reserved for business entities, employers, property owners or landlords, not other practitioners.
Add Additional Insured - $10 per Additional Insured
Select # of Additional Insureds
1 Additional Insured 2 Additional Insured 3 Additional Insured 4 Additional Insured 5 Additional Insured 6 Additional Insured 7 Additional Insured 8 Additional Insured 9 Additional Insured 10 Additional Insured 11 Additional Insured 12 Additional Insured
Additional Insured Individual #1
Additional Insured Individual #2
Additional Insured Individual #3
Additional Insured Individual #4
Additional Insured Individual #5
Additional Insured Individual #6
Additional Insured Individual #7
Additional Insured Individual #8
Additional Insured Individual #9
Additional Insured Individual #10
Additional Insured Individual #11
Additional Insured Individual #12
Insurance Plus includes professional (malpractice) liability, general ('trip & fall') liability, product liabiltiy: $2 million of protection per year / $3 million aggregate / $2 million product aggregate, $100,000 rental damage, $15,000 identity protection and $1,000 lost or stolen equipment coverage. Pricing is in U.S. Funds.
MASSAGE Magazine
YES! I would like to add MASSAGE Magazine at this special discounted rate available only to Insurance Plus members only. (normally $19.95 per year)
Upon submission of this application, your policy becomes effective on the date selected above. Your payment will be reflected on your credit card statement this month. Your Annual payment may include $9.95 for a 1-year subscription to MASSAGE Magazine. Please note that you are covered for a 12 month period starting on the effective date you selected.
Do not put any spaces or dashes when entering your Credit Card Number.
First Name on card:
Last Name on card:
Credit Card Type:
Select One...
Visa
Master Card
American Express
Discover Card
Credit Card Number(no dashes or spaces) :
Expiration Date:
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1 2 3 4 5 6 7 8 9 10 11 12
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2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Billing Street:
Billing City:
Billing State:
Select one...
AL AK AZ AR AS CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY
Billing Zip Code: (5 digits only)
Billing Phone Number:
Authorization and Disclosure
I represent that the above statements are true and no material facts have been suppressed or misstated. As of this date, I have no knowledge of any allegation, claim or lawsuit or any act, error or omission, which might reasonably be expected to result in a claim or lawsuit. I further represent that, to the extent required, I am licensed to practice in accordance with all relevant federal, state and local requirements.
I authorize coverage issuance and the above statement is true to the best of my knowledge. I also understand that once this credit card payment is processed, there is no cancellation, refund or partial refund available.
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