Volunteer Accident Insurance Application 011521 Page 1 of 1 aliverisk.com
APPLICATION FOR: Volunteer Accident Insurance
Policyholder Information
Policyholder Name: ___________________________________________________________________________________________
Mailing Address: _____________________________________________________________________________________________
Contact Name: ____________________________________________ Phone Number: _____________________________________
Contact Email Address: _____________________________________ Insured Email Address: _______________________________
Plan and Benefits
Effective Date: ____________________________ Expiration Date: _____________________________
Maximum Medical Expense Benefit: $ ________________ Accidental Death & Dismemberment Principal Sum: $ _____________
Deductible (per claim): $ ________________
Type of Coverage: Excess Primary Coverage for: All Volunteers of the Policyholder
Number of Enrollees to be Insured: _______________ Number of Staff to be Insured: _______________
Types of activities the volunteers are performing? ___________________________________________________________________
Prior Coverage
Have you had prior coverage? Yes No
What is the current number of volunteers? _____________ Premium: $ ________________
Has coverage ever been declined or canceled due to losses? Yes No
Declaration and Signature
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.
_______________________________________________________________________ ____________________________
Authorized Signature Date
_______________________________________________________________________ ____________________________
Printed Name Title
Agent Data
Agent Name: ____________________________________________ Agency: ____________________________________________
Address: _____________________________________________________ City/State/Zip: __________________________________
Phone: ______________________ License Number: _______________________ Email: __________________________________
Signature: __________________________________________________________ Date: ___________________________________
Alive Risk is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a subsidiary of Ryan Specialty Group, LLC
(RSG). Alive Risk works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the public. Some products may only be available in certain states, and some products may
only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC (License # 0G97516). ©2021 Ryan Specialty Group, LLC
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