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.