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:
   

 

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