liability insurance for your energy practice€¦ · sgd mnm hmu@rhud m@stqd ne ntq oq@bshbd @mc...

Protection for You and the Practice You Love

Liability Insurance for Your Energy Practice

Association for Comprehensive Energy Psychology

For All Energy Medicine and Energy Health PractitionersVolunteers, Students, Practitioners and Instructors

• Low Cost – Professional Liability Protection • Practicing In Your Home, Office, While Traveling and/or When Volunteering • Coverage Specifically Tailored for Energy-based Practice

ACEP

in association with

Do I need Liability Insurance for my Energy Medicine, Energy Psychology or Energy Healing Practice?This is a question you need to be asking yourself if you are seeing

clients – as a student, a practitioner with a private practice, an instructor, or a

volunteer.

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age for liability insurance is quite low – starting at $215 for students and $240

for practitioners.

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Ş� Client safety in your place of business is your responsibility. Whether your business is located in your

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Energy Medicine Professional Liability Insurance Rev. 05.2012


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Bottom line – when you have professional and general liability insurance you are free to provide your services,

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It is easy to apply.�2HLOKX�ƥKK�NTS�SGD�@OOKHB@SHNM�HM�SGHR�O@BJDS�@MC�L@HK�NQ�E@W�SN�SGD�'3/ �NƧBD



Three Insurance Levels Offered

Ş��Student Member Liability ($215 annually)

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Ş��Practitioner Member Liability ($240 annually)

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Ş��Instructor Member Liability ($340 annually)

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Ş��Additional Insured��+@MCKNQC�NQ�+NRR�/@XDD��HR�@U@HK@AKD�TONM�QDPTDRS �3GDQD�HR�@�ʙ��ODQ�BDQSHƥB@SD��@CLHMHRSQ@SHUD�EDD

Comprehensive Coverage

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Coverage Coverage Description Coverage Limits

Professional Liability

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General Liability "NUDQR�BK@HLR�ENQ�HMITQHDR�SG@S�NBBTQ�@S�XNTQ�OK@BD�NE�

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NE�VGDM�SGNRD�BK@HLR�@QD�QDONQSDC



Personal and Advertising Injury /QNSDBSR�XNT�EQNL�RTHSR�HMUNKUHMF�KHADK��RK@MCDQ�NQ�

wrongful invasion of privacy.



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Aggregate

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$2,000,000

%HQD�#@L@FD "NUDQR�C@L@FD�SN�SGD�RO@BD�XNT�VNQJ�HM $100,000

4LAQDKK@�+H@AHKHSX Provides an additional $1,000,000

coverage over the coverages listed above.

$1,000,000

Additional Information:

Ş��No deductibles for general liability or professional liability

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Main Exclusions:�$PTHMD�SQD@SLDMS��RDWT@K�@ATRD�LNKDRS@SHNM��CDRHFM@SDC�OQNCTBS�DWBKTRHNM�HMBKTCDR�@KK�OQNCTBSR�HMFDRSDC�NQ�S@JDM�HMSDQM@KKX


Membership Level: choose one

Student Member Liability Annual Cost: $215 Includes Liability coverage for students of energy therapies that practice part time up to 6 hours per week.

Practitioner Member Liability Annual Cost: $240 Includes Liability coverage for Energy Medicine Professionals that have completed their training in a specific energy practitioner program. This covers full time practice over 6 hours per week. Includes insurance to teach classes of up to 9 students.

Instructor Member Liability Annual Cost: $340 Includes insurance to teach classes of 10 to 99 students as well as the Practitioner liability coverage.

This is an annual policy that renews every year on April 1st and your premium is prorated based on the month you enroll. Coverage renews for a full year each April 1st. Prorated premiums are listed in the table below. Cost includes surplus lines tax and administrative fees.

Other Options:

Additional insured (landlord) $10 per each certificate administrative fee.$10 x _______ each certificate

Please print or type all information. Incomplete applications will not be processed. Allow one week for processing. Because a signature is required no application will be accepted over the phone.

Membership and Insurance Preferences

Energy Medicine Professional Liability Insurance Application Rev. 05.2012 ACEP Page 1 of 4

Membership Level Cost:

(see chart based on your enrollment month)

$ _______________

$ _______________

$ _______________

Other Options Cost:

TOTAL COST:

MAIL APPLICATION/PAYMENT TO:Energy Medicine Professional Insurance20822 Cactus Loop, Suite 300San Antonio, TX 78258or Fax (210) 497-8532Questions? Call (210) 497-5529www.EnergyMedicineProfessionalInsurance.com

Name:

Phone: Fax: Business Name:

State: ZIP Code:

Years in practice?

Mailing Address:

City:

E-mail:

Energy Medicine Professional MEMBER APPLICATION forGENERAL LIABILITY and PROFESSIONAL LIABILITY INSURANCE

Offered Through Healing Touch Professional Association (HTPA)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Student 215.00 197.08 179.17 161.25 143.33 125.42 107.50 89.58 71.67 53.75 35.83 17.92

Practitioner 240.00 220.00 200.00 180.00 160.00 140.00 120.00 100.00 80.00 60.00 40.00 20.00

Instructor 340.00 311.67 283.33 255.00 226.67 198.33 170.00 141.67 113.33 85.00 56.67 28.33

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We understand that many practitioners in the Energy Medicine field have training in a number of modalities. You may receive coverage for a number of modalities provided you have a basis of training in a professional program that ensures that you are a safe practitioner.

Please check all modalities you seek coverage for and include a certificate of class completion/participation for each and return with your application (see page 4 for more information on submitting certificates).


Subtle Energy F Acupressure F Alexander Technique F Applied Kinesiology F Aura Healing & Aura Reading F Barbara Brennan Healing Science F Breathwork F Bodytalk F Clairvoyant Reader F Color Therapy F Craniosacral Therapy F Crystal Healing F Eden Energy Medicine F Emotional Freedom Technique (EFT) F Energetic Healing (EH) F Energy Balancing F Energy Field Work F Energy Tapping F Esoteric Healing F Jin Shin Jyutsu F Healing Touch F Healing Touch For Animals (excl. Equine) F Healing Touch Spiritual Ministry F Integrated Energy Therapy® (IET) F Kinesiology F LifeLine Technique F Lionheart Institute’s Energy Healer F Magnified Healing F Matrix Energetics F Pranic Healing F Polarity Therapy F Psych-K F Quantum Touch F Reconnective Healing F Reiki F Rising Star Healing F Rosen Method F Shamballa Multi-Dimensional Healing F Shamanic Healing F Sound Healing F Tapas Acupressure Technique (TAT)

Subtle Energy Continued F Therapeutic Touch F Thought Field Therapy (TFT) F Touch For Health F Zero Balancing

Verbal Modalities F Guided Imagery F Hypnotherapy F Energy Psychology F Health Coaching F Laughter Leader F Life Coaching F Spiritual Counseling

Massage Therapy F Complete Massage Technique Page F Reflexology

Movement F Feldenkrais Method F Pilates F Qigong F T’ai Chi F Yoga

Subtle Energy of the Senses F Aromatherapy F Raindrop Therapy F Therapeutic Musicians

Assessment F Biofeedback F Iridology

Additional Modalities:


Massage Techniques Please complete this section of the application if you are a massage therapist. Check all that apply in your practice:


Light/Medium F Abdominal Massage F Amma Therapy F Bowen Technique F Chair Massage F Esalen Massage F Hot Stone Massage F Infant Massage F Integrative Massage F Lomilomi Massage F LooyenWork F Lymph System Massage F Myotherapy F Naprapathy F Neuromuscular Therapy F Ortho-Bionomy Loosely F Pregnancy Massage F Rubenfeld Synergy Method F Sport Massage (Medium) F Swedish Massage F Thai Massage

Deep F Aston Patterning F Canadian Deep Muscle Massage F Cross Fiber Massage F Deep Muscle Massage F Deep Tissue Massage F Hellerwork F Pfrimmer Deep Muscle F Rolfing F Sport Massage (Deep) F Structural Integration

Other:

Do you use machinery or instruments in your practice? yes no Describe:

Do you own or lease a building or office? yes no

Location: ___________________________________________________________________________________Sq Ft: ___________

Additional Insured Cost $10 per each certificate issued. List below certificates needed. Use separate sheet if needed.

1. Landlord’s or Loss Payee Name: _________________________________________________________________________________________

Address: _____________________________________________________________________________________________________________

City, State, ZIP Code: __________________________________________________________________________________________________

2. Landlord’s or Loss Payee Name: _________________________________________________________________________________________

Address: _____________________________________________________________________________________________________________

City, State, ZIP Code: __________________________________________________________________________________________________


Signature

Payment

Submit Your Application

Have you ever had a claim filed against you? yes noMembers with claim history are subject to company approval.

If yes, describe: Use separate page if needed.

Do you know of a situation that might result in a claim? yes no

Describe: Use separate page if needed.

F I agree to have my clients sign an informed consent which contains this statement: I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against YOUR NAME.

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 signature shall verify that I have completed this application accurately and honestly. 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 that 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.

When your application is completed click the submit button below to electronically send it. Once your application is received processing time takes approximately one week. Your certificate of insurance will be emailed to the email address you provided. - Please be sure to submit your certificate(s) of completion (from page 2).

A copy can be emailed to [email protected] or faxed to (210) 497-8532. You may also mail copies to the address on page 1 of this application. Your application can not be processed without payment or copies of your certificate(s).

Method of Payment:

Check# __________ for $ __________ Make check payable to EMPI

Credit Card: Visa MC Discover # _________________________________________________________________________

Amount to card $ __________ EXP Date __________ Three digit safety code __________

Office Use Only: Auth # _____________________________________ CC Order # _____________________________________


Signature of Applicant: Date:

Click here to Save Your Application

Click here to Print Your Application

Click here to Submit Your Application

liability insurance for your energy practice€¦ · sgd mnm hmu@rhud m@stqd ne ntq oq@bshbd @mc...

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