Student Insurance, Athletic Accident Coverage, Special Risk Insurance, Summer Camps, Little Leagues

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1st Sports Camp/ Special Risk: Information Request

IN ORDER TO BEST SATISFY YOUR INSURANCE NEEDS, PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION.

Name of Organization

Address Line 1 *

Address Line 2

City *

Postal / Zip Code *

State / Province / Region *

Country

Phone Number *

Email *

PLEASE LIST THE FOLLOWING:

1. Type of Activity

2. Type of Activity

3. Type of Activity

4. Type of Activity

5. Type of Activity

1. No. of Participants

2. No. of Participants

3. No. of Participants

4. No. of Participants

5. No. of Participants

1. Age Group

2. Age Group

3. Age Group

4. Age Group

5. Age Group

1. Effective Date

2. Effective Date

3. Effective Date

4. Effective Date

5. Effective Date

1. Termination Date

2. Termination Date

3. Termination Date

4. Termination Date

5. Termination Date

Are activities listed above overnight?

Yes No

If yes, which ones?

CURRENT COVERAGE: ACCIDENT MEDICAL

1. Carrier

1. Deductible

1. Maximum

1. Premium

CURRENT COVERAGE: LIABILITY

2. Carrier

2. Deductible

2. Maximum

2. Premium

COVERAGE OPTIONS TO BE QUOTED

Accident Medical coverage may be provided by itself or in conjunction with the Liability Coverage

Accident Medical Coverage Only

Quote Current Coverage

Other

If other, please describe

Liability Coverage?

Yes No

Date Quote Needed

1st Sports Camp/ Special Risk: Information Request

CONTACT US

Address

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