Policy Holder (full legal name)
Contact Name (first and last)
Number of years in business
Specified Activities (0/500)
Current Insurance Company
WARNING: READ CAREFULLY!
Each school or studio must install a Release and Waiver of Liability and indemnity Agreement for all students and staff members. Unintentional error on your part in securing Waiver and Release forms shall not void your coverage in the event of any occurrence to a student or staff member. However, your failure to maintain an adequate system to regularly secure Waiver and Release forms shall void your coverage in the event of an occurrence to a student or staff member. A Waiver/Release form will be emailed to your school or studio upon request. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer submits application or files claim containing a false or deceptive statement may be guilty of insurance fraud. The minimum premium on this program is $475.00 (or $540.00 depending on state) which is also the minimum earned. What this means is if you cancel your insurance, the insurance company will keep the minimum premium and not return any portion to you. Any premium amount in excess of the $475.00 (or $540.00 depending on the state) minimum may be returned on a prorated basis if you cancel coverage.
MEDICAL EXPENSE BENEFITS AGREEMENT
If the Covered Person incurs eligible expenses as the direct result of a covered injury and independent of all other causes, the Company will pay the charges incurred for such expense within 365 days, beginning on the date of accident. Payment will be made for eligible expenses in excess of the applicable Deductible Amount, not to exceed the Maximum Medical Benefit. The first such expense must be incurred within 90 days after the date of the accident. “Eligible expense” means charges for the following necessary treatment and service, not to exceed the usual and customary charges in the area where provided.
- Medical and surgical care by a physician
- Radiology (X-Rays)
- Prescription Drugs and medicines
- Dental Treatment of sound natural teeth
- Hospital care and service in semi-private accommodations, or as an outpatient
- Ambulance service from the scene of the accident to the nearest hospital
- Orthopedic appliances necessary to promote healing
Excess coverage: This plan does not cover treatment or service for which benefits are payable or service is available
under any other insurance or medical service plan available to the Covered Person.
Exclusions and Limitations
This plan does not cover any loss to or resulting from:
- Suicide, self-destruction, attempted self-destruction or intentional self-inflicted injury while sane or insane.
- War or any act of war, declared or undeclared
- Sickness, disease or any bacterial infection, except one that results from an accidental cut or wound or pyogenic infections that result from accidental ingestion of contaminated substances.
- Voluntarily taking any drug or narcotic unless the drug or narcotic is prescribed by a Physician.
- Covered Expenses for which the Covered Person would not be responsible in the absence of this Policy.
- Injuries paid under Workers’ Compensation, Employer’s liability laws or similar occupational benefits or while engaging in activity for monetary gain from sources other than the Policyholder.
- Injury caused by, contributed to or resulting from the Covered Person’s use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person’s Physician.
- Service or Active Duty in the armed forces, National Guard, military, naval or air service or organized reserve corps of any country or international organization.
- Services or treatment rendered by a Physician, Nurse or any other person who is employed or retained by the policyholder; or an immediate Family member of the Covered Person.
- Treatment of a hernia, Osgood-Schlatter’s disease, osteochondritis, appendicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, whether or not caused by a Covered Accident.
- Damage to or loss of dentures or bridges or damage to existing orthodontic equipment, except as specifically provided in this Policy.
- Eyeglasses, contact lenses, hearing aids.
- Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from: While riding as a passenger in any aircraft not intended or licensed for the transportation of passengers.
Abuse or molestation, aircraft, all acts of terrorism, asbestos liability, assault and battery, collapse of temporary structure, owner auto coverage, employment related practices, fungi and bacteria, hepatitis, HIV, HTVL, AIDS, transmissible spongiform encephalopathy, lead poisoning, medical payments, nuclear energy liability, professional liability, pyrotechnics activity, total pollution, war liability, and liability for occurrences prior to the effective date of coverage. All of the above are subject to the terms and conditions of the policy.
Note: There is no liability coverage for claims arising out of any of the following activities: All motor sports, ballooning, bungee jumping, cheerleading pyramids, gymnastics, inflatables, luge, mountain climbing, parachuting, polo, rock climbing, rodeo or any equestrian-related sports, sale/manufacture or distribution of any athletic equipment, skin diving, SCUBA diving, snow skiing, squash, tobogganing, use of saunas, white water rafting, water craft, or any saddle animal exposures.
You must accept the terms of our
Medical Expense Benefits
agreement to continue
I accept the terms
I do not accept the terms
To add a dance recital to your policy now, please complete the section below. Price reflects a three (3) day recital. Dance recitals lasting longer than three (3) days must be quoted on an individual basis so you would need to email us for the quote. We will make every effort to send your certificate within 24 hours if your application was made during normal business hours. (Normal business hours are M-F 9:00 am to 5:00 pm EST). Dance recital coverage premium is an additional $100.00 for 200 or less participants. If you have over 200 participants, there will be an additional charge of $ 0.50 for each participant over 200. If you have more than 2 additional insured to your recital, please e-mail us
Recital Additional Insured Information
Additional Insured 1
Additional Insured 2
Would you like to add Contents Coverage?
MANDATORY FRAUD WARNING STATEMENTS BY STATE
"Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."
VIRGINIA, TENNESSEE, MAINE
"It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits."
"It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of insurance and civil damages.
Any insurance company or agent of an insurance company who knowingly provides false, incomplete,
or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies."
"WARNING: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines.
In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant."
"Any person who knowingly and with intent to injure, defraud, or deceive any insurer
files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree."
"Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any materially false information or conceals,
for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime."
Insurance applications must contain this statement:
"Any person who includes
any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties."
"ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS
FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES."
"Any person who knowingly and with intent to defraud any insurance company
or other person files an application for insurance or a statement of claim
containing any materially false information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
"Any person who, with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud."
"WARNING: Any person who knowingly, and with intent to injure, defraud or
deceive any insurer, makes any claim for the proceeds of an insurance policy
containing any false, incomplete or misleading information is guilty of a felony."
Purpose of misleading "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 information or conceals for
the information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties."