Instructor Change Request Form General Information Instructor name submitting change* First Last Please select which instructor program you have and need to update:* Dance Instructor Fitness Instructor Martial Arts/Self Defense Instructor Sports Instructor Current policy effective date:* MM slash DD slash YYYY Policy Number (As it appears on your certificate of Insurance) Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone* Email* Program Change Request Please select what you are trying to change on your current policy below* Update Contact Information Change Coverage Type Add an Eligible Activity Change Limit of Coverage Other Effective date needed for change* MM slash DD slash YYYY Update Contact Information Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Website Change Coverage Type Type of Change:* Non-Certified to Certified (Copy of certification required) Certified to Non-Certified Upload Copy of Updated Certification Max. file size: 256 MB. Add an Eligible Activity Please indicate the activity you would like to add to your current instructor policy:* Please review your instructor program to view current approved eligible activities. Other activities outside current approved activities are subject to approval. Change Limit of Coverage Limit change may require additional premium upon approval. Please indicate your current liability limit: Please indicate the new limit requested: Other Policy Changes Please indicate the change would like like to make to your current instructor policy:
