Affordable Martal Arts Insurance quote form

Mikkelsen Insurance Services

Information needed for Martial Arts Accident and Liability Insurance quote (California Only)! Please complete all blanks. (Our Privacy Statement)

Name:
Name of School or Studio:
Address:
City:	CA
Zip code:
Phone:
Current carrier:
Expiration date:

What styles of Martial Arts are taught? Please be specific:

Please give brief discription of your qualifications:

Yes	No
		Do you distribute any herbal, medicinal or nutritional products?
		Do you provide instruction in private residences?
		Do you provide or render acupuncture?
		Are kicking motions to the head permitted without headgear?

Has any prior insurance been canceled in the last three years? Please give details:

Total number of students in the busiest month of the year?

Additional information:

E-mail address:

Be sure all questions are answered. We are unable to respond to requests with incomplete information.



For a FREE quote please complete the form and press "Send" or if you prefer you may print it and Fax it to us at: 209-839-8632