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Participant Accident Insurance Request for Quote Form – Businesses/Organizations/Groups

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

Other...

risk other choice

If sports is checked above, please specify 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

Are you a business or organization currently NOT working with an insurance broker?

Yes

No

If you have a broker, please enter their name and contact info here

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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© 2024 Great American Insurance Company. All Rights Reserved. Great American Insurance Group’s member companies are subsidiaries of American Financial Group, Inc. (AFG). AFG is a holding company whose common stock is listed on the New York Stock Exchange. Policies are underwritten by Great American Insurance Company, an authorized insurer in all 50 states and the DC.