Please enable javascript to continue.

Our site relies on it to provide you with an enjoyable mobile user experience.

Otherwise, you may visit our .

Circus Instructors

General & Professional Liability Insurance Application

Denotes Required Fields

Your Coverage: $1,000,000 per occurrence / $3,000,000 aggregate limit

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 the effective date.
Next >

Business/Personal Info

First Name

Last Name

Email Address

Phone Number
Cell Phone

Next >

Home & Mailing Address

Home Address:
Street Address

City

State

Municipality
Zip Code

*Louisiana locations are not eligible for this program

Mailing address is same as home address

Mailing Address:
Street Address

City

State

Zip Code

Next >

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.
General Liability coverage is written through the Fitness & Wellness Risk Purchasing Group and a fully earned & nonrefundable fee of $50.00 is required to join the Risk Purchasing Group.

Additional Insured

Does the facility where you conduct business require you to list them as an Additional Insured on your policy and provide them with a Certificate of Insurance (COI)?

Yes

Name:
Email:
Phone:
Fax:
Street:
City:
State:
Zip:

+ Add Another

Available Payment Methods

e-check

Credit Card (Includes convenience fee)

Billing address is same as home address

Address

City

State

Zip Code

Name on Bank Account

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.

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

SSL

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.

To:

Subject:

Body:
Attachment:

Please enable javascript to continue.

Our site relies on it to provide you with an enjoyable mobile user experience.

Circus Instructors

General & Professional Liability Insurance Application

Policy Effective Date

Background Information

Business/Personal Info

Home & Mailing Address

Purchase Information

E-mail this page

E-mail Reminder

Application Error

Swipe

Press & Hold

Share this page!

Chat with Us!

E-mail:

Please enable javascript to continue. Our site relies on it to provide you with an enjoyable mobile user experience.

Circus Instructors

General & Professional Liability Insurance Application

Policy Effective Date

Background Information

Business/Personal Info

Home & Mailing Address

Purchase Information

E-mail this page

E-mail Reminder

Application Error

Swipe

Press & Hold

Share this page!

Chat with Us!

Please enable javascript to continue.

Our site relies on it to provide you with an enjoyable mobile user experience.