Fair Volunteer Group Accident Insurance Application 011521 Page 1 of 2 aliverisk.com
APPLICATION FOR: Fair Volunteer Group Accident Insurance
Fair / Festival / Event Name: ____________________________________________________________________________________
Facility Name: _______________________________________________________________________________________________
Street Address: ___________________________________________ City, State, Zip: _____________________________________
Contact Name: ____________________________________________ Phone Number: _____________________________________
Contact Email Address: _____________________________________ Insured Email Address: _______________________________
Describe Volunteer Activities: ___________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Accident Medical Coverage
100% Usual & Customary Plan Benefits*
Dental Benefit Included
$2,500 Physical Therapy Benefit
Full Excess
Benefits Premium Calculation
$25,000 Medical Expense Benefit Maximum per injury Number of Volunteers: ______________
$5,000 Accidental Death & Dismemberment X $3.00 Premium Each = $ ____________
Deductible $100 per injury Policy Fee = $75.00
Total Due = $ ____________
Minimum Premium and fee is $375. If premium is less, you must pay $375.
Benefits Premium Calculation
$50,000 Medical Expense Benefit Maximum per injury Number of Volunteers: ______________
$10,000 Accidental Death & Dismemberment X $4.50 Premium Each = $ ____________
Deductible $100 per injury Policy Fee = $75.00
Total Due = $ ____________
Minimum Premium and fee is $575. If premium is less, you must pay $575.
Benefits Premium Calculation
$100,000 Medical Expense Benefit Maximum per injury Number of Volunteers: ______________
$15,000 Accidental Death & Dismemberment X $6.00 Premium Each = $ ____________
Deductible $100 per injury Policy Fee = $75.00
Total Due = $ ____________
Minimum Premium and fee is $675. If premium is less, you must pay $675.
*Coverage is $100 primary/excess in states GA, IL, IN, MA, NH. Coverage is not available under this plan in KS, MD, MN, MO, OR,
SD. Ask agent about coverage in these states.
Applicant Signature
By signing below, Applicant understands that the information provided in this document is intended to be a summary of coverage only.
Complete coverage details are provided in the insurance policy and available upon request. Applicant declares information provided is
true and that no material facts have been suppressed or misstated. Applicant understands false statements or misrepresentations may
result in termination of this insurance contract. I understand Coverage is not in effect until coverage is accepted by the Insuring
Company and binder has been provided to me.
_______________________________________________________________________ ____________________________
Authorized Signature Date
_______________________________________________________________________ ____________________________
Printed Name Title
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signature
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