Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date

MM

DD

YYYY

Which Service Would You Like for Your Team? *

Vibroacoustic Therapy + BrainTap & Chair Massage

Chair Massage

Yoga

Vibroacoustic Therapy + BrainTap

Does your company need insurance: *

Primary, Noncontributory: Ensures our insurance is primary and will not seek contribution from other policies. Additional fee $25.

Specific Waiver of Subrogation: Prevents our insurer from seeking recovery from another party. Additional fee $25.

Loss Payee: Designates a third party to receive insurance proceeds in the event of a loss. Additional fee $25.

Primary, Noncontributory & Waiver of Subrogation: Combines the primary, noncontributory, and waiver of subrogation endorsements. Additional fee $45.

CG 20 37 Additional Insured – Owners, Lessees, or Contractors – Completed Operations: Provides coverage for completed work. Additional fee $30.

CG 20 11 Additional Insured – Managers or Lessors of Premises: Adds coverage for managers or lessors of premises. Additional fee $30.

Earlier Notice of Cancellation Provided by Us: Ensures earlier notice of policy cancellation. Additional fee $55.