Dance Insurance Application
Please complete the form below to apply for dance insurance coverage.

E-Mail
Verify E-Mail
Password
Policy Holder (full legal name)
Address
City
State
Zip
Contact Name (first and last)
Phone
Cell
Mailing Address
City
State
Zip
Business Type
Number of years in business
Specified Activities (0/500)
Effective Date
Current Insurance Company
Have you recently had a liability claim within the last 5 years?
Yes
No

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.
I Accept
I do not Accept *


Do you have a release waiver on file for each student?
Yes
No
   

If so, are both signatures required for minors?

Yes
No
   


Has any prior coverage been cancelled or not renewed?
Yes
No


Does your organization currently utilize a waiver system?
Yes
No


Does your organization have a risk management plan?
Yes
No


Coverage Amount
Participants
Cost Estimate: 0
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.

Liability Exclusions

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



Additional Locations

Do you have any additional locations?
Yes
No




Additional Insureds

Do you have any additional insureds?
Yes
No


Add a Dance Recital

Would you like to add dance recital coverage to your policy?
Yes
No


Content Coverage

Would you like to add Contents Coverage?
Yes
No