eMartial Arts Insurance - Application Information

Applicant Information

Fields marked with an asterisk (*) are required.

Business Name

Name of Studio/Business: Please be sure your business name exactly matches what is on your lease and other business documents!	*
Note: This is the name that will appear on your Certificate of Insurance. If your company is a Sole Proprietorship, then this will be your personal name or DBA.

Contact Information

Policyholder First Name:	*	Policyholder Last Name:	*
Additional Contact First Name:		Additional Contact Last Name:
Phone Number 1: No Formatting - Example 7705551212	*	Phone Number 2: No Formatting - Example 7705551212	*
Fax Number:	*
E-mail Address:	* This is the email address we will use for contacting you about all insurance matters. Brokers, enter your email address.	Confirm E-mail:	*
Web Site Address:

Mailing Address

Mailing Address 1:	*	Mailing Address 2:	*
City:	*
State:	*
If your business has a location in New York, Washington or New Hampshire, your application will have to be reviewed by the insurance office.
Zip Code: 5 digits or 5-4	*

Is this Mailing Address also a Studio Location where classes will be held? * Yes No
Classes taught in a home are not covered.

Studio Location(s)

Studio Location #1:

Studio Address 1:	*	Studio Address 2:	*
City:	*
State:	*
Zip Code: 5 digits or 5-4	*

Would you like to enter additional Studio Locations where classes will be held? * Yes No

Studio Location #2:

Studio Address 1:	*	Studio Address 2:	*
City:	*
State:	*
Zip Code: 5 digits or 5-4	*

Studio Location #3:

Studio Address 1:	*	Studio Address 2:	*
City:	*
State:	*
Zip Code: 5 digits or 5-4	*

Studio Location #4:

Studio Address 1:	*	Studio Address 2:	*
City:	*
State:	*
Zip Code: 5 digits or 5-4	*

Studio Location #5:

Studio Address 1:	*	Studio Address 2:	*
City:	*
State:	*
Zip Code: 5 digits or 5-4	*

Insurance Broker Use To be recognized as an insurance broker and eligible for a commission you must be an approved broker with our company and you must answer Yes to the following question and supply the other broker information requested. If you are not approved, you must contact us before applying for coverage.

Are you an Insurance Broker? Yes No

Broker Name:	*
Email Address:	*
Agency Name:	*
Phone Number No Formatting - Example 7705551212	*

eMartialArtsInsurance a division of eSportsInsurance

Applicant Information