If you are not a member of ACSM or ACSM certified please click here to apply for insurance through our Allied Health Program
Does your education qualify you for your profession?*
Are you licensed in accordance with federal/state requirements?*
Are you requesting a quote for Group/Business Coverage?*
Do any of those applying for coverage have any ownership interest in the firm?*
Do you have clients sign a liability waiver before participating?
Has waiver wording been reviewed and approved by legal counsel?
Do your clients have more than 25 employees that will utilize your services?
Are you currently insured for professional liability through another carrier / plan?*
Is the current coverage*
Do you wish to purchase coverage back to your first date of purchase for an additional premium?*
Have you ever had your license, certification or registration revoked?*
Have you had any complaints or charges brought against you by any licensing board or professional ethics body?*
Have you ever been convicted of a felony?*
Have you ever had your professional liability insurance cancelled or non-renewed?*
Have you ever had a claim or suit made against you, or are you aware of any incident that might reasonably lead to such a claim or suit?*