Insurance Payment Submission Form

Hello, please fill out and submit the form below. Once we receive your completed form, we will go ahead and send you the invoice via PayPal/or Stripe (You can pay via debit/credit) for the payment option you choose in the form. Once payment is received, we will send the official background check request via our partner Checkr aswell as submit your information to our insurance company. We do not offer any refunds on this payment once it has been submitted.

You will NOT be prompted to pay, be billed or charged within this form. An invoice or pay link will be sent to you within 24 hours of receiving your submission.

Please note that your insurance policy will end on 3/30/2024

Insurance Payment Submission Form

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please select what payment option you choose(Required)

$25 Up-front payment with a $32 deduction from your pay when you start teaching lessons

Full $57.00 Payment

4 Weekly Installments of $14.25

*Please note that the total insurance payment is $57.00. If you choose the payment plan of the 4 weekly installments, you will be sent a payment page link to set up your payment plan for your insurance policy. If you choose the deduction payment plan, you will be sent an invoice of $25 which must be paid up front before becoming insured with us.

Do you agree and understand that once payment is made and your insurance policy is processed, we cannot refund your payment under any circumstances.(Required)

I Agree & Understand

*Please note that once you submit payment and we submit and process your insurance plan under our general liability policy, we cannot offer any refunds. Reason being is because our insurance company does not allow any refunds once the policy is processed.

Do you agree and understand that if you choose to opt in for our payment plan, that any outstanding balance must be paid regardless of your employment status with InstaSwim.(Required)

I Agree & Understand

Do you agree and understand that if you choose to opt in for our payment plan, if for any reason your contract is ended and you are no longer working with InstaSwim, your outstanding balance must be paid regardless of your employment status with InstaSwim.

Do you agree and understand that this insurance coverage covers you ONLY for clients that InstaSwim sends to you in the 2023 year ONLY?(Required)

I Agree & Understand

Meaning, this liability insurance policy will only cover you for InstaSwim clients, not clients that you sourced on your own. This coverage is only good for clients that are sent your way from March 30th, 2023, to March 30th, 2024.

Insurance Payment Submission Form

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