www.karateinsurance.com

Martial Arts Insurance Program

 

Please complete the following application and submit to bind coverage. If you have any questions, please email or call 970-547-0362 and ask for Don Baldwin. Unfortunately we can not accept any new business in Rhode Island.

School Information

Name of School:
Mailing Address:

State:

  
City:

Zip:
 School Owner:

Phone #:
Email Address:

Website:
Type of Business:

Where did  you hear about us?                        

Number of Students:

 
The rate is $8.95 per student with a $450 minimum premium.  If you have 50 students or less, you are at the minimum.

Tournament Coverage - Are you hosting a tournament in the near future you would like add to you policy now?  The charge is $100 for 200 or less participants.
(Only for traditional Martial Arts Tournaments.  If you are hosting MMA or kickboxing, please give us a call)
Please add this coverage (check here) Date of Tournament # of Participants # of Spectators
 

What Style do you teach?  Please be specific.

Has any prior coverage been cancelled or non renewed? If Yes check here and please explain below. Otherwise enter "no"

Have you had a liability loss in the past 3 years? If Yes check here and please give the details below. Otherwise, enter "no"

Are you an insurance agent submitting this application for your client?  If so, please enter your name, phone number and email address.

   
Does your organization currently utilize a waiver system?     Yes     No  For a copy of the waiver, click here.
Does your organization currently have a risk management plan?     Yes     No  If you answer "no" the insurance company will send you one.
     

Location Information - (If you have more than four locations or need more than four certificates, please email or call us.)

  Location #1 Location #2 Location #3 Location #4
Street Address:
City:
State:
Zip:
         
         

Request Evidence/Certificate of Insurance

Complete this section if you need to provide evidence of insurance to a landlord, gym, municipality, school or others.   If you need to know the difference between a certificate holder and an additional insured, please click here. If you have more than 4 additional insured's, please contact us.  How many additional insureds do you need to add to your policy?
 
  Location Location Location Location
Certificate Holder:
Mailing Address:
City:
State:
Zip:
Relation to insured:
Additional Insured:

Contents Coverage (optional) - Once you submit your application, you will be given an option for a property quote.

Payment Information

The soonest we can bind your insurance is the day following receipt of payment.  If you pay with a credit card, we can bind as early as tomorrow.  If you mail us a check, coverage will be bound the day after we receive it. Currently only accepting American Express, Visa and MasterCard.

What date would you like coverage to start?

 (mm/dd/yyyy) Leave blank if paying by check

How would you like to pay for your new insurance?

  
   
We keep the costs down for this program by doing as much by internet and email.  If you do not have an email address and want  your policy mailed, there is an additional charge is $10.00 to cover postage and handling.  Policy Deliver Method: 
  Send policies to the above email address
 Send policies the above mailing address. I understand and additional $10.00 will be added to my premium.

 

        

Secure Credit Card Payment
 

Card Type

     

Name as it appears on card:

Card Number:

 16 digits, no space or dashes

Card Expiration Date:

 (MM/YY)  
 

CVS #:

 If you are not sure where to find the CVS #, Click Here
 

 
 
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 full supply of Waiver and Release forms shall be shipped 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 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 premium to you.  Any premium above the minimum will be returned on a prorate basis if cancelled.

Check that you have read the above statement

Once you hit the submit button, all your information will be transferred electronically.  The following page will be confirmation of payment and evidence of insurance for certificate holders. You should print this page for your records.  Your insurance policies, claim form, additional information and waiver if needed will be emailed to you within a couple of days in Adobe/PDF format. 

Don Baldwin
Grizzly Insurance Agency, LLC
PO Box 5530
Breckenridge, CO  80424
970-547-0362  Fax 303-484-4431