Terms and Conditions of Insurance
I hereby state that I have no knowledge of any incident, pending claims, suits, or other ethics violations nor have any been filed against me in the past pertaining to my practice as a practitioner, that no certifications or licenses have been revoked, and that I have never been arrested for or been charged with any sexual violation.
I understand that this application is subject to approval with no automatic inclusion in the program. My digital signature shall verify that I have completed this application accurately and honestly and that I agree to provide proof of training should I be asked to provide it in the event of a claim.
I understand that I am responsible to verify that the coverage is appropriate to my training and professional activity, and that activities outside the scope of coverage of the policy are not covered.
I understand that any false statement made on this application or subsequent renewals shall void this application and render my insurance coverage null and void.
I understand and agree to pay a $35 charge-back fee if my payment is disputed or refunded by a third party.
I understand that if my applicationis approved, the premium/fees paid by me are nonrefundable, nontransferable and will not be prorated. This application is for a policy which will expire 12 a.m. April 1 each year. Denied applications will be refunded less any associated fees resulting from the method of payment (i.e. credit card charges).
I understand and agree to follow the EMPA Code of Ethics and understand that activities outside the EMPA Code of Ethics may void coverage.