Get Instant Quote Contact and Practice Information:Full Name (First, Middle, Last)*Practice / Clinic Name*Office Address (include Suite #) Street Address City State / Province / Region ZIP / Postal Code Mailing Address – If Different from Office Address Street Address City State / Province / Region ZIP / Postal Code Office PhoneAlternate Phone (Home, Cell, etc.)FaxEmail Practice Information License: Is your fitness license current? Yes No N/A - Certification only. No licensure in my state Certifications: Please include a copy of any Fitness Professional Certifications you hold. Do you hold any healthcare licenses (RN, LMT, DC, etc.)? Yes No If Yes, listDo you provide dietary advice to clients? Yes No If Yes, do you limit your advice to general, non-medical advice? Yes No Do you assert to your clients that you treat any condition, disease or injury other than guiding them in managing their general fitness and overall well-being? Yes No If Yes, explainGeneral Background (If you answer Yes to any of the following, attach a detailed explanation including status, dates, and outcomes) Claim History: Has any malpractice claim or allegation ever been asserted against you or your associates Yes No Potential Claims: Are you aware of any event or indication suggesting a claim may be made against you or that your care might have been deficient or caused harm? Yes No License Issues: Has any agency or association ever investigated or taken any action against you or your license? Yes No Insurance: Have you ever had malpractice insurance denied, canceled, or accepted on special terms? Yes No Criminal History: Have you been charged with or convicted of violating any law other than a minor traffic offense? Yes No Compromised Care: Have you ever provided care to patients when your ability to perform your professional duties was compromised because of a condition, or your use of an intoxicant, medication, or other drug? Yes No Coverage InformationWho provides your current malpractice policy?ExpiresYour malpractice coverage, if approved, is effective the date the app is received. For a later date, specify dateDo you need Retroactive Coverage Yes No If Yes, indicate your desired retroactive date (charges may apply)If you practice using a Professional Corp or Partnership, which you own, list below to add it, free of charge, as an Additional InsuredList below to add any other entity added as an Additional Insured (e.g. your Employer, Landlord, etc.). Cost is 5% per entity This iframe contains the logic required to handle Ajax powered Gravity Forms.
