Music Teachers National Association — FRANCIS L. DEAN & ASSOCIATES, LLC

MUSIC TEACHERS NATIONAL ASSOCIATION

LIABILITY INSURANCE PROGRAM ENROLLMENT

Please complete the below application form in order to enroll for individual music instructor liability insurance.

YOU CAN MAKE PAYMENT VIA CREDIT / DEBIT CARD

(3% CREDIT CARD FEE IS ADDED TO RATE PLAN BELOW - EXCEPT FOR FL POLICYHOLDERS)

OR

BY CHECKING OR SAVINGS ACCOUNT (NO FEE IS ADDED).

Name

First Name

Last Name

Phone

(###)

###

####

Email

Address

City

State

Zip Code

Your Coverage Start Date

MM

DD

YYYY

PRICING OPTIONS

COVERAGE START DATE BETWEEN 9/26/24 - 3/26/25 (COST: $176.00)

COVERAGE START DATE BETWEEN 3/27/25 - 6/27/25 (COST: $125.00)

COVERAGE START DATE BETWEEN 6/28/25 - 9/26/25 (COST: $75.00)

CREDIT/DEBIT CARD NUMBER

3% FEE WILL BE ADDED TO ALL CREDIT/DEBIT CARD PAYMENTS.

EXPIRATION DATE

3-DIGIT SECURITY CODE (MOST CARDS) OR 4 DIGIT CODE ON FRONT OF CARD FOR AMEX

IF PAYING VIA CHECKING - ENTER NAME OF BANK

NO FEES ADDED TO CHECKING/SAVINGS ACCOUNT PAYMENTS.

NAME ON CHECKING/SAVINGS ACCOUNT

9-DIGIT ROUTING NUMBER

CHECKING/SAVINGS ACCOUNT NUMBER

I AUTHORIZE FRANCIS L. DEAN & ASSOCIATES TO CHARGE MY PAYMENT INFORMATION PROVIDED ON THIS FORM.

I AGREE