Massage Insurance Sign Up Form 128 bit encryption keeps you safe and your information secure.
Personal Information
* First Name:
* Last Name:
Company:
Title:
* Address:
* City:
* State:
* Zip Code:
* Home Phone:
* Work Phone:
Fax:
* Birthdate:
* Social Security:
* E-mail:
* Password:
* Denotes required information
Insurance Information
Terms and Conditions
Create a Pop Up
I have read and agree to the terms and conditions. (Default is unchecked)
Plan Information
$119.95, 1 year practicing for PROFESSIONALS
$79.95, 1 year practicing for STUDENTS
The insurance company requires that you have written permission to use any type of implement or equipment other than your body parts in your practice. For permission, please submit each type of Implement/equipment with a brief description:
Add my business information on iWantaMassage.com referral services
If they check this box, maybe we should ask some of the same questions we ask on iwam? Rates, Techniques etc.
Automatic Renewal Option
Your Insurance plan will automatically renew annually based on the information provided above. Please uncheck box if you do not want automatic renewal.
Payment Information
Name On Card:
Credit Card Type:
Credit Card Number:
(no spaces please)
Expiration Date:
Mo Yr.
Billing Street:
Billing City:
Billing State:
Billing Zip Code:
Authorization and Disclosure
I represent that the above statements are true and no material facts have been suppressed or misstated. I attest that, as of this date 04/18/2006 I have no knowledge of any allegation, claim or suit or any act, error or omission, which might reasonably be expected to result in a claim or suit.
I authorize coverage issuance and the above statement is true to the best of my knowledge.
