Participant Accident Insurance Quote Request Form
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1P RTICIP NT
CCIDENT INSUR NCE
QUOTE REQUEST FORM
Name of
Organization:____________________________________
Contact:
____________________________
ddress:______________________________________
City:
__________________
State:
_______
Zip:
________
Email:___________________________
Phone:
_________________________
Fax:
__________________________
gent
Name:____________________________________
gency:
_______________________________________
ddress:______________________________________
City:
__________________
State:
_______
Zip:
________
Email:___________________________
Phone:
_________________________
Fax:
__________________________
Requested Effective Date of Coverage:
__________________________
1. Do you currently have ccident coverage?
Yes
No
( f Yes, please provide a copy of your current policy’s schedule page.)
2. Describe who will be covered:
______________________________________________________________
______________________________________________________________________________________________
3.
Provide a brief description of the types of activities to be covered:
__________________________
______________________________________________________________________________________________
4.
Estimated Number of Participants by ctivity:
ctivity
Duration of
Number of Participants
ctivity
12 & Under
13 – 15
16 – 18
Over 18
5.
Previous Experience: (Please provide a copy of your current policy’s schedule page.)
Current Year
20____
20____
20____
20____
Premium
Paid Claims
s of Date
Insurance Carrier
-
Request for Quote:
Please provide an ccident Insurance quote based on the information provided on this form and any
attachments. To the best of my knowledge, all information provided is complete and accurate.
Signed:
_______________________________________ Title:_______________________
Date:
___________________
lease return form to:
The llen J. Flood Companies, 2 Madison ve., Larchmont, NY 10538
info@ jfus .com • Phone: 1-800-734-9326 • Fax: 1-914-834-9330
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