Fitness Individual General & Professional Liability Insurance Application

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Fitness Individual

General & Professional Liability Insurance Application

Select your Coverage

Requested Policy Effective Date

Effective Date:
Policy Effective date must be greater than the current date and within 60 days of the current date.
Policy Expiration date defaults to (1) year following effective date.

Personal information

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Style/Profession:

Certification:

First Name:

Last Name:

Email:

Retype Email:

Please ensure the email address you are entering is valid. All policy communication such as renewal notification and policy delivery will be handled via email. Your policy will not be delivered by mail.

Phone: - -

Cell Phone: - - (optional)

Home Address:

City:

State:

Municipality:

Zip:

*Louisiana locations are not eligible for this program

Mailing Address: Mailing address is the same as home address

Purchase Information

Please review the purchase information below.

Policy Premium*: $

State Premium Surcharge: $

Risk Purchasing Group Fee: $

Total Payment Amount: $

*All rates are subject to underwriter approval

Additional Insured What's this?

Yes

Payment Information

Available Payment Methods

e-check

Credit Card (Includes convenience fee)

Name on Bank Account

Bank Name

Bank Routing #

Bank Account #

Confirm Bank Account #

Bank Account Type

Consumer Authorization for Direct Payment Via e-check

Direct Payment via ACH is the transfer of funds from a consumer account for the purpose of making a payment.

I authorize Philadelphia Insurance Companies to electronically debit my account. I understand the payment will be debited from the account in 24-48 hours from the time of authorization and there is no revocation.

Billing Address: Billing address is the same as home address

The following states are excluded from credit card fees: CT, MA, and RI.

Clicking the button below will launch a popup window where you must verify your address.
After address verification, you will navigate back to this page.
E-check payments - Click the button again to submit the application.
Credit card payments - Click the button again to access the payment page.

Please wait while your application is being submitted.

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Fraud Notice

Notice to applicants:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES.

*Note: The above proposal may not account for local taxes mandated by the State in which you/your business operate(s). The final policy will include a description of how local taxes, if applicable, have been allocated as determined by the risk location. Please contact a PHLY representative if you have any questions.

The Insurer may not be subject to all of the insurance laws and regulations of your resident state.