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.
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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
$2 million per occurrence,
$3 million annual aggregate,
$2 million products and completed operations annual aggregate;
$100,000 rental damage insurance;
Identity Protection Plan;
and $1,000 stolen equipment coverage.
Choose your program:
Only students enrolled in their initial license or certification
course for the profession selected as primary modality qualify for a
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
Please no spaces
Check this if the billing address for credit card is the
same as address above.
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 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. Every enrollee in the insurance product is charged $5
as a broker placement fee and for administration of the RPG.