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Martial Arts Insurance Application


 

Select a Payment Method


Credit/Debit Card (online)
Check/Money Order
Igomag User Name & Password
Your User Name and Password will allow you to access and update your account information in the future. It is advised that you only use STRONG Passwords. Strong passwords consist of random combinations of letters, numbers and symbols. "Y!?;6bHqkx" is an example of a strong password. You may access your account, at any time, in the future, via our Client Services Section.

We suggest using your e-mail address as your user name
User Name
Password must be 7-30 characters long
Password
Verify Password


Please make a note of your User Name and Password for future reference.
You will need them to access and update your application.


Security Question & Answer
You will use this information if you need to
recover your password in the future
Security Question
Answer
Verify Answer
Business Website
Your E-Mail Address
Verify E-Mail
Address 1
School Name
Customer Name (First & Last)
School Address
City
State
Zip
Mailing Address (If different from above)
Address
City
State
Zip
Phone ( ) -
Cell (optional) ( ) -
Fax (optional) ( ) -
Business Type
Years in Business

 

Instructions Provided


  • Cardio
  • Kickboxing
  • Aikido
  • Judo
  • Jiu Jitsu
  • Karate
  • Tae Kwon Do
  • Tai Chi
  • Kung-Fu
  • Shotokan
  • Kenpo
  • Brazilian Jui Jitsu
  • MMA
  • Hapkido
  • Kempo
  • Capoeira
  • Boxing
  • Ninjitsu
  • Nunjitsu
  • Other Instructions (separate with comma) (0/500)


    Date that you would like coverage to start*

     





    Excess Limits
    Please contact Martial Arts Group if you would like to add Excess Limits to your policy.


    Current Insurance Company

    Have you recently had a liability claim within the last 5 years?
    Yes No 


    Students

    Amount of coverage *Most requested by landlords (95%)



    Accidental Medical Coverage Limit: $100,000 USD
    Your Deductible: $500 USD


    WARNING: READ CAREFULLY!
    Each school or studio must install a Release and Waiver of 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 any 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 a student or staff member. A Waiver/Release form will be emailed to your school or studio upon request. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer submits application or files claim containing a false or deceptive statement may be guilty of insurance fraud. The minimum premium on this program is $490.00 which is also the minimum earned. What this means is if you cancel your insurance, the insurance company will keep the minimum premium and not return any portion to you. Any premium amount in excess of the $490.00 minimum may be returned on a prorated basis if you cancel coverage.
    I Accept I do not Accept *

    Yes No    Do you have a release waiver on file for each student? *
    Yes No    If so, are both signatures required for minors? *
    Yes No    Do you offer Contact Boxing? *
    Yes No    Do you permit contact of any kind? *

    Yes No    Are Sparring rules addressed and given to all students? *
    Yes No    Does your school practice/teach Historic European Martial Arts (HEMA)? *

    Additional Locations
    Do you have any additional locations?
    Yes No


    Additional Insureds
    Do you have any additional insureds?
    Yes No


    Content Coverage
    Would you like to add Contents Coverage?
    Yes No
    MANDATORY FRAUD WARNING STATEMENTS BY STATE

    ARKANSAS, LOUISIANA
    "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
    presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."

    VIRGINIA, TENNESSEE, MAINE
    "It is a crime to knowingly provide false, incomplete or misleading information to an insurance
    company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits."

    COLORADO
    "It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
    insurance company for the purpose of defrauding or attempting to defraud the company.
    Penalties may include imprisonment, fines, denial of insurance and civil damages.
    Any insurance company or agent of an insurance company who knowingly provides false, incomplete,
    or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
    attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
    insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies."

    DISTRICT-OF-COLUMBIA
    "WARNING: It is a crime to provide false or misleading information to an
    insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines.
    In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant."

    FLORIDA
    "Any person who knowingly and with intent to injure, defraud, or deceive any insurer
    files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree."

    KENTUCKY
    "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."

    NEW JERSEY
    Insurance applications must contain this statement: "Any person who includes
    any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties."

    NEW MEXICO
    "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT
    CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS
    FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A
    CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES."

    NEW YORK
    "Any person who knowingly and with intent to defraud any insurance company
    or other person files an application for insurance or a statement of claim
    containing any materially false information concerning any fact material thereto, commits a
    fraudulent insurance act, which is a crime, and shall also be subject to a civil
    penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."

    OHIO:
    "Any person who, with intent to defraud or knowing that he is facilitating a fraud
    against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud."

    OKLAHOMA
    "WARNING: Any person who knowingly, and with intent to injure, defraud or
    deceive any insurer, makes any claim for the proceeds of an insurance policy
    containing any false, incomplete or misleading information is guilty of a felony."

    PENNSYLVANIA
    Purpose of misleading "Any person who knowingly and with intent to defraud
    any insurance company or other person files an application for insurance or
    statement of claim containing any materially false information or conceals for
    the information concerning any fact material thereto commits a
    fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties."

    I accept the terms I do not accept the terms *



    Do you have a risk management plan?
    Yes No *


    I hereby certify that all above
    information is true and correct

    Signature (Typed name indicates signature)


    Today’s Date * (October/17/2017)