SPORTS CAMP / SPECIAL RISK INFORMATION REQUEST FORM
IN ORDER TO BEST SATISFY YOUR INSURANCE NEEDS, PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION.
Name of Organization:
Address:
City:
State:
Zip Code:
Telephone Number:
INFORMATION PROVIDED BY:
Name:
Title:
Telephone Number:
PLEASE LIST THE FOLLOWING::
TYPE OF ACTIVITY
NUMBER OF PARTICPANTS
AGE GROUP
EFFECTIVE/TERMINATION DATES
ARE ACTIVITIES LISTED ABOVE OVERNIGHT?
Yes
No
IF YES, WHICH ONES?
CURRENT COVERAGE:
ACCIDENT MEDICAL:
Carrier:
Deductible:
Maximum:
Premium:
LIABILITY:
Carrier:
Deductible:
Maximum:
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:
Deductible:
$0
Quote Current Coverage
Other:
LIABILITY COVERAGE:
Yes
No
Quote Current Coverage
Other:
DATE QUOTE NEEDED:
