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Participant Accident Insurance Request for Quote Form
Requested Effective Date of Coverage
Quote Due Date
MM slash DD slash YYYY
Client Information:
Company
Name
Email
Address
City
State
Zip
Website
Risk Information:
Select a choice
Camps
Non-Profits
Childcare
After School Activities
Youth Sports
Health + Fitness
K-12 Schools
Collegiate Activities
Special Events
Other...
risk other choice
If sports is checked above, please list which sports:
Day Participants
Overnight Participants
Total Number of Participants
If applicable, please provide the number of participants by age.
12 and Under
13-15
16-18
19 and Older
Maximum Age
Description of covered persons (who is to be covered)
Describe covered activities
Travel To/From
Yes
No
Desired benefits:
Accidental Death
Accidental Dismemberment
Accidental Paralysis
Accidental Medical Expense
Select a choice
Excess
Primary
Maximum Benefit Period
52 weeks
104 weeks
Other Benefits Requested
Aggregate limit per occurrence (standard is 10 times the Accidental Death benefit)
Prior coverage:
is there a plan currently in force?
Yes
No
If yes, please provide carrier name
Effective date
MM slash DD slash YYYY
Producer Information:
Name of agency
Contact
Address
City
State
Zip
Phone
Email
Requested commission: 15% is standard
Are you a licensed A&H producer in the applicable risk state(s)?
Yes
No
Are you an appointed producer with Great American Insurance Company?
Yes
No
I here by acknowledge that all answers and statements contained on this form are complete and accurate. I also understand that no coverage will become effective until an application has been approved by the Company.
Please email any attachments to
[email protected]
.
Initial to agree to the above statement.
Date
MM slash DD slash YYYY
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