PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR
INDIVIDUAL ALLIED HEALTHCARE PROFESSIONALS
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Purchase Confirmation
Select your status as an allied healthcare professional:
If you are both employed & self-employed, please select self-employed as your status
Employed
(you provide services on behalf of an entity you do not own, and receive a W-2 form from your employer)
Self-Employed
(you provide services as an independent contractor, and pay self-employment taxes using a 1099 form)
Student
(you are a student who does not currently hold a license or certification and are not currently practicing in the profession for which you are seeking coverage)
State of Residence:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
How many hours do you work per week?
How many years experience do you have relevant to your profession?
Less than 1 year
Greater than 1 year, less than two years
Greater than 2 years, less than three years
Greater than three years
Please select all occupations for which you are requesting coverage. If you are a student, and do not currently hold a healthcare license or certification, please select your primary area of study.
Art Music Dance Recreational Therapists
Art Therapy Assistant
Certified Fitness Trainer
Certified Personal Trainer
Dance Therapy Assistant
Fitness Therapist
Holistic Fitness Trainer
Music Therapy Assistant
Occupational Therapist
Occupational Therapy Assistant
Physical Therapist Employed
Physical Therapist Self Employed Full Time
Physical Therapist Self Employed Part Time
Physical Therapy Assistant
Pilates Instructor
Recreational Therapy Assistant
Speech Pathologist
Yoga Instructor
Requested Effective Date of Coverage:
Application # 12712295