* = required field

Name of School or Studio*
Email*	Fax 999-999-9999
Street Address*
City*	State*   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   Zip Code*
Phone*	999-999-9999
Name of Owner(s)*
Effective Date of Coverage*	Termination Date of Coverage
Are you a*	Select Corporation Municipality Partnership Health Club Park District Individual LLC
What styles of Martial Arts are taught? Please be specific.*
Has prior liability coverage been cancelled or non-renewed in the past 3 years?*	... Yes No If yes, please explain:

Waiver Requirement Each school or studio must install a Release and Waiver or 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 an 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 student or staff member.  A full supply of Waiver and Release forms shall be shipped to your school or studio upon request.

 

Premium Calculation (choose your Liability Aggregate)

General Aggregate Amount:	Selcet One $1,000,000.00 $2,000,000.00
$1,000,000.00 at $8.95 / pp  (Minimum Premium is $450.00)   OR   $2,000,000.00 at $9.25 / pp  (Minimum Premium is $465.00)
Total number of students in the busiest month of the year
Add Optional Hired/Non-Owned Auto Coverage at $850.00	No Yes
	**
** Please note:  Minimum Program Premium is $450.00 for policies with $1,000,000.00 General Aggregate and  $465.00 for $2,000,000.00 General Aggregate. The Minimum Premium does not include the optional hired and non-owned automobile liability coverage.  The Premium amount calculated above will be verified by DHC Insurance.