Renew

Which province do you reside in?*
Standard Policy Premium / Please select one of the following:*
- $210.60 RENEWAL SAMGATA $2,000,000 Policy
- $259.20 RENEWAL SAMGATA $5,000,000 Policy
(Includes 8% PST)
Optional International Web Based Consulting/Teaching Coverage:
- $54.00 International Web Based $5,000,000 Coverage (Includes 8% PST)
If you consult with clients via the internet (website, social media), international phone consultation, skype or face time, you need International Web Based Consulting/Teaching coverage offered for a $5,000,000 limit, for these consultations ONLY.
Standard Policy Premium / Please select one of the following:*
- $206.70 RENEWAL SAMGATA $2,000,000 Policy
- $254.40 RENEWAL SAMGATA $5,000,000 Policy
(Includes 6% PST)
Optional International Web Based Consulting/Teaching Coverage:
- $53.00 International Web Based $5,000,000 Coverage (Includes 6% PST)
If you consult with clients via the internet (website, social media), international phone consultation, skype or face time, you need International Web Based Consulting/Teaching coverage offered for a $5,000,000 limit, for these consultations ONLY.
Choose one of the following options:*
- $195.00 RENEWAL SAMGATA $1,000,000 Policy
- $240.00 RENEWAL SAMGATA $5,000,000 Policy
Optional International Web Based Consulting/Teaching Coverage:
- $50.00 International Web Based $5,000,000 Coverage
If you consult with clients via the internet (website, social media), international phone consultation, skype or face time, you need International Web Based Consulting/Teaching coverage offered for a $5,000,000 limit, for these consultations ONLY.

Business Name
(enter if applicable)
First & Last Name*
First Last
Address*
Street Address Address Line 2 City Postal Code
Phone*
Fax
Email*
Enter Email Confirm Email

Do you practice any modalities other than Yoga and/or Pilates?*
- Yes
- No
If you wish to add modalities, please list below:*
(Please note: There may be an additional charges for certain modalities)
Do you have a training certificate for all the modalities you are practicing?*
- Yes
- No
How many hours of training have you received?

*You must keep a copy of your training certificate(s) on file as we may request a copy in the future. You do not need to send us one at this time.
By submitting this application, you attest that the application has been completed accurately and honestly. No disciplinary action has been taken or is pending against you. You have never been the subject of any investigation, either civil or criminal, in connection with any sexual act, conduct, molestation, and/or assault. You understand that your insurance certificate will provide evidence that you have been added as an individual participant with respect to the coverage and limits of the Master Policy. You understand that the coverage provided by your insurance certificate is subject to all the terms, conditions and exclusions contained in the Master Policy. You further understand that the Insurance Company will rely on the information you have provided in the application. You are also able to provide a certificate of training for the modality you practice on your policy upon request. Failure to pay required premiums and/or false statements on this application or subsequent renewals shall void this application and render your insurance coverage null and void, and you may be subject to further legal action if making false statements.
Please indicate your agreement:*
- I Agree
- I Disagree
Note: This is just an order form; it does not confirm insurance. If you require immediate documentation please provide your fax number.
Name
This field is for validation purposes and should be left unchanged.

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