PRIVATE PRACTICE EDUCATORS PROFESSIONAL LIABILITY

Completion of this enrollment form confirms your desire to obtain insurance through the Sports, Leisure and Entertainment Risk Purchasing Group. The submission of this enrollment form and/or acceptance of payment does not guarantee coverage. Certain operations are not eligible for coverage by this program. Myron Steves reserves the right to decline any request for coverage.

    TO AVOID PROCESSING DELAYS, PLEASE:
  • Complete all sections
  • Sign and date where required
  • Remit completed enrollment form with payment

Online Application
GENERAL INFORMATION:
Individual's full name (as it should appear on policy):        
  (the legal name of the individual; typically the name that would appear on any contracts or agreements)

If applying other than an individual, please list entity name & type (Corp., LLC, partnership, or other):  
Coverage disclaimer

Please note that this insurance will only provide coverage for your operations as an individual educational instructor receiving a 1099. Coverage does not extend to your business, your employees, or anyone performing instruction or training on your behalf. In addition, coverage applies only to educators of students ages K-12.

Mailing Address:    
City:
  State:
select
Zip:  
Contact Name:
  Phone:  
Cell:
Fax:  
Email:      

DATE:
Coverage will begin the day after the completed enrollment form and premium are received and approved, or on a later date you specify below. (If renewing coverage, please provide the expiration date of your current policy.)
Start my coverage on this date:  
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Open the calendar popup.
 

BUSINESS INFORMATION:
Do you receive a 1099?  
By who are you paid? (note - if paid by staffing agency, coverage cannot apply)  
Please provide a detailed description of the educational activities the applicant performs and for which coverage is desired.  
What is the age group of your students:  
Please list your qualifications and certification/licenseure as an educator:  
Are you a member of a professional educator association(s) in Texas?  
If yes, please list:
Are you a member of an educator association outside of the state of Texas? If yes, please list.  
If yes, please list:
Do you have an insurance agent who is representing you on this Private Practice coverage?
If yes, please list their name and phone number.

ADDITIONAL INSURED REQUESTS:
Complete this section to request additional certificates. Provide seperate requests for each additional certificate needed.

An additional insured is an entity which has an insurable interest for claims arising out of your negligence as the named insured. Such possible entities are the school or the school district. By providing an entity additional insured status, it is now entitled to defense and indemnity (if policy limits have not been exhausted) under your policy with no responsibility for enrollment form, or in writing via email to Lori Pack at lpack@myronsteves.com. Please remember to provide the complete name and address.
Certificate holder/entity name:
Mailing Address:  
City:
State:
select
     
Zip:

PREMIUMS AND FEES ARE 100% FULLY EARNED AND NON-REFUNDABLE ONCE COVERAGE BEGINS:
Per Educator: $214.00
Agency Administrative Fee: $  99.00
Total Payment: $313.00
 |  Card Number:   
Reference number (last 3 digits on back of card):   | Expiration Date: 
select
    
select
 
I authorize Myron Steves & Company to charge my payment to my credit/debit card in the amount of $313.00
Name as it appears on card:   
Administrative Fee:
$71.00 if a memember of a professional educator association in Texas
$99.00 if not a member of a professional educator association in Texas
$99.00 if a non-Texas resident

Coverage is offered exclusively through Sports, Leisure and Entertainment Risk Purchasing Group (RPG). Educators in Private Practice fall within the Sports, Leisure and Entertainment RPG master policy. Submission of this enrollment form confirms your desire to receive coverage through the RPG.


  
Myron Steves & Company • P.O.Box 77210 • Houston,TX 77210-4479 • 1-800-392-1604 • Fax 1-800-294-0851 • www.myronsteves.com