Allied Health Care - Mental Health Counselor / Therapy Services Supplement

Allied Health Care – Mental Health Counselor : Therapy Services Supplement APP PDF Download

Allied Health Care - Mental Health Counselor / Therapy Services Supplement

  • This supplemental application is incorporated into and is deemed a part of the other application(s) submitted in connection with the requested insurance. Any and all notices and representations included in such other application(s) are incorporated by reference in this supplemental application as though fully set forth herein.

  • (Please type full name in space provided)
  • (Please use your mouse on a PC or Mac, or your finger or stylus on a tablet or smartphone to sign your name.)

  • (Required in New Hampshire)

    (Please use your mouse on a PC or Mac, or your finger or stylus on a tablet or smartphone to sign your name.)

  • This document does not amend, extend or alter the coverage afforded by the policy. For a complete understanding of any insurance you purchase, you must first read your policy, declaration page and any endorsements and discuss them with your broker. A specimen policy is available from an agent of the company. Your actual policy conditions may be amended by endorsement or affected by state laws.
  • This field is for validation purposes and should be left unchanged.