Applicant Information

Operations

Number of employees / independent contractors in each position (enter 0 if none)

Services Offered

Please answer for each of these services, even if you do not offer it.

Athletes

Aquatic therapy

Dry needling / acupuncture, wellness & spinal manipulation

Please upload a complete list of the dry needling / acupuncture and wellness services offered on the last page.

Tests & products

Prior Carrier Information

Risk Management

Heat therapy / electrical stimulation guidelines should address: clients with impaired, sensitive or numb areas; temperature control and maintenance of water and hot packs; and mentally impaired individuals or those with heat sensitivity.

Has the applicant, or any of its employees / contractors, ever been subject to any of the following?

Data Breach Questions

Attachments

Please provide copies of the following current policy declarations pages showing effective dates, retro dates and limits, so underwriting can match limits and applicable retroactive dates:

Scope, Warranty, Fraud Warning & Signature

This insurance does not apply to any of the following: physician, surgeon, dentist, nurse midwife, chiropractor, podiatrist, osteopath or psychiatrist. Unless otherwise provided by endorsement, these medical professional occupations are excluded from coverage. The insurance described herein is subject to all terms, conditions and exclusions of the policy.

Applicant's Warranty Statement: The undersigned represents, to the best of his / her knowledge and belief, that the particulars and statements set forth are true, and agrees that those particulars and statements are material to the acceptance of the risk assumed by the insurer. The undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue or incomplete any statement made will immediately be reported in writing to the insurer, and the insurer may withdraw or modify any outstanding quotations and / or authorization or agreement to bind the insurance. The signing of this application does not bind the undersigned to purchase the insurance, nor does the review of the application bind the insurer to issue a policy. It is understood the insurer is relying on the application in the event the policy is issued. It is agreed that this application, including any material submitted therewith, shall be the basis of the contract should a policy be issued, and may be attached to and become part of the policy.
Must be signed by a principal, partner or officer of the group, or by the individual applying for insurance.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false, incomplete or misleading information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and may subject the person to criminal and civil penalties, including fines, imprisonment and denial of insurance benefits. State-specific fraud notices (including AL, AR, CO, DC, FL, KS, KY, LA, ME, MD, NJ, NM, NY, OH, OK, OR, PA, RI, TN, VA, WA and WV) apply and will be provided by the insurer where required.

By checking "I Accept", the applicant consents and agrees that using a keypad, mouse or other device to check "I Accept" constitutes the applicant's signature, acceptance and agreement as if signed by the applicant in writing, with the same force and effect as a handwritten signature. The applicant also agrees that the lack of a certification authority or other third-party verification will not affect the validity or enforceability of the signature or any resulting contract.

Must be signed by a principal, partner or officer of the group, or by the individual applying for insurance.