Coverage Application

Professional Information

For questions 1 through 8: If you answer yes, provide full details.

1. Has any malpractice claim or proceeding ever been brought against you, your associates or employees, or are you aware of any circumstances that would give rise to such a claim?
   Claim - YES Claim - NO
    

2. Has any government agency investigated, suspended, revoked, or taken any other action against your license to practice massage?
   Government Agency - YES Government Agency - NO
    

3. Have you ever had malpractice insurance refused, declined, canceled, or accepted on special terms?
   Malpractice - YES Malpractice - NO
    

4. Have you ever used any intoxicant, narcotic, or other psychoactive drugs to the extent that it has interfered with your ability to perform professional duties; or used any illegal drug in the past year?
   Drugs - YES Drugs - NO
    

5. Have you ever been convicted of any violation of the law other than a minor traffic offense?
   Conviction - YES Conviction - NO
    

6. Has any professional association suspended, revoked, or taken any other adverse action against you or your membership in any such association?
   Membership - YES Membership - NO
    

7. Do you do colonic irrigations, treat cancer, epilepsy, practice obstetrics or make a differential diagnosis?
   Alternative Treatments - YES Alternative Treatments - NO
    

8. Do you use any technique or therapy that is not currently taught in the massage schools?
   Technique - YES Technique - NO
   
   Details for YES answers to questions 1 through 8:
   Details:
    

9. Do you wish coverage for any other person or entity?
   The first two additional insureds are $25 each, all others are free.
   
   Additional Insureds - $25 (First 2 are $25 each, all others free)
   QTY:
   
   Additional Insureds - Free
   QTY:
   
   List Name(s) of all Additional Insureds:
   
    

10. List other health professions you are licensed to practice (D.C. L.Ac., etc.)
    
    
    Provide the name of your malpractice insurance carrier for that profession:
    
    
    Expires:

11. Is license current. License Current - YES License Current - NO
12. Povide Florida Massage Therapy License #
13. Date license issued:
14. What school did you attend:
    When did you graduate: (mm/yy)
    

Member Declaration: I hereby apply for malpractice insurance. I declare that the statements made in my Risk Purchasing Group Membership Application are true and that I have not suppressed or misstated any facts and I agree that this declaration shall be a basis for, and form a part of my malpractice insurance policy. I understand that untrue statements could void my insurance policy.

Exclusions: I understand that in addition to excluding acts outside the scope of practice of Massage Therapy, this Policy also excludes other conditions and acts as specified in Section V of the Massage Professional Coverage Endorsement to the Policy, including but not limited to exclusions for claims arising out of the use of colonics; any alleged sexual act; and the treatment of cancer.

Claims-Made Only: I understand that if a policy of insurance is issued based on the statements in this application, except as otherwise provided in that policy, the policy is limited to claims made against, the insured during the policy period arising out of the rendering or of failure to render professional services subsequent to the retroactive date. I understand that if the policy terminates due to nonpayment of premium or cancellation by the insured or insurer, there is no coverage for claims reported after the termination date (even though the injury occurred while the policy was in force) unless the insured purchased an Extended Coverage Policy within 30 days after termination.

Duty to Report Incidents: I understand that there is no guarantee that coverage will be renewed. I also understand that any price distinctions base don safe message practices may be based in part on information provided by me on future follow-up data sheets or during future pre-arranged office inspections. I understand that, if coverage is granted, I shall have the duty to report in writing, within 3 days, or as soon as practicable, any incidents reasonably likely to involve this insurance, including oral or written patient complaints, or threats or filings of lawsuits.

By submitting this insurance application, you are stating that you understand and agree with the statements above.