Athletic Trainer Insurance Plus membership will be effective upon the effective date entered
at the top of the form. Membership term is 12 or 24 months depending on your policy.
Athletic Trainer Insurance Plus is not responsible for discontinuing any payroll/credit
card allotment process you may have with any other Professional
I represent that the above statements are true and no material facts have been suppressed
or misstated. As of this date it is understood and agreed that I have no knowledge of any past, pending or current:
(a) claims, lawsuits, complaints, allegations, (b) acts, errors or omissions which may reasonably be expected to become a claim or lawsuit.
I further represent that, to the extent required, I am licensed to practice in
accordance with all relevant federal, state and local requirements and my license is
current and active. I understand and agree that I am covered for the modalities listed on
the Insurance Plus website only to the extent that they are included in the scope of work
as defined by the federal, state or local jurisdiction that regulates my professional
activities. I acknowledge that the Effective Date of coverage must be either the
application submission date or a future date. Applications cannot be submitted with an
Effective Date of coverage that precedes the date of application. In addition, I
acknowledge that professional services rendered under the influence of drugs or alcohol
are excluded from coverage. I understand that if I am practicing Yoga Therapy, I have
selected it as my profession or other discipline above.
Upon submission of this application, your policy becomes
effective on the date selected above. Your payment will be
reflected on your credit card statement this month. Every enrollee in the insurance product is charged $5
as a broker placement fee and for administration of the RPG.