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.
Your free website will be available as soon as we process this application.
Your InsureLMT policy will be effective upon the effective date entered at the top of this form for 12 months.
InsureLMT Insurance Plus is not responsible for discontinuing any payroll/credit card allotment process you may have with any other Professional Liability provider.
Additional Insured - An additional insured is a person or business entity protected by endorsement from the named insured's negligence. It is not meant to protect other practitioners.
Throughout the span of your policy, you may likely have to add additional insureds. The cost of additional insureds can add up. Why not save this expense by purchasing the Unlimited Additional Insured Package?
Insurance Plus provides professional and general liability insurance, $2 million per occurrence, $3 million annual aggregate, $2 million products and completed operations annual aggregate; Identity Protection Plan;
Choose your program:
Only students enrolled in their initial license or certification course for the profession selected as primary modality qualify for a student policy. If you are not a student on the effective date of coverage, all insurance is null and void and no claims will be paid. Our student policies will only cover the discipline you are in school for when your coverage begins.
Option not available with your current insurance policy selection.
Upon submission of this application, your policy becomes effective on the date selected on page one. 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.
Please no spaces
Visa/Mastercard/Discover
American Express
Check this if the billing address for credit card is the same as address above.
insureLMT membership will be effective upon the effective date entered at the top of the form. Membership term is 12 or 24 months depending on your policy.
insureLMT is not responsible for discontinuing any payroll/credit card allotment process you may have with any other Professional Liability provider.
I represent that the above statements are true and no material facts have been suppressed or misstated. As of this date it is understood and agreed that I have no knowledge of any past, pending or current: (a) claims, lawsuits, complaints, allegations, (b) acts, errors or omissions which may reasonably be expected to become 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 and my license is current and active. I understand and agree that I am covered for the modalities listed on the Insurance Plus website only to the extent that they are included in the scope of work as defined by the federal, state or local jurisdiction that regulates my professional activities. I acknowledge that the Effective Date of coverage must be either the application submission date or a future date. Applications cannot be submitted with an Effective Date of coverage that precedes the date of application. In addition, I acknowledge that professional services rendered under the influence of drugs or alcohol are excluded from coverage. I understand that if I am practicing Yoga Therapy, I have selected it as my profession or other discipline above.
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. Pricing includes a $50.00 Risk Purchasing Group Fee, 3% Delaware State Surplus Lines Taxes, and identity fraud protection. Other fees are applicable based upon individual applicants coverage selections.
