Fillable Application - All Other Groups36-10691

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Application - All Other Groups36-10691

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PARTICIPANT ACCIDENT INSURANCE QUOTE REQUEST FORM
Name of Organization:
Street Address:
City:
State:
Zip:
Contact:
Email:
Phone:
Fax:
Requested effective date of coverage:
1.
Do you currently have Accident coverage?
No
If yes, please submit a copy of the expiring policy and currently-dated loss runs for the
most recent five policy years.
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 Activity
Activity
Duration of Activity
Number of Participants by Age Group
12 & Under
13 – 15
16 -18
Over 18
ACKNOWLEDGEMENTS AND SIGNATURES
a.
Fraud Warning
It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
b.
Applicant’s Acknowledgement I, the Applicant, declare, to the best of my knowledge and belief, that all
statements and answers in this application are true and complete. I understand and agree that (a) this application
will form part of any policy issued, (b) no information given to or acquired by any representative of Philadelphia
Indemnity Insurance Company will bind it, unless it is in writing on this application, (c) no waiver or modification will
bind the Company unless it is in writing and is signed by an executive office of Philadelphia Indemnity Insurance
Company and (d) only those persons eligible under the terms of an issued policy will be insured.
Signed:_________________________________________
Title:
Date:
Agent Name:
Agency:
Address:
City:
State:
Zip:
Email:
Phone:
Fax:
Please return form to:
Philadelphia Insurance Companies, 500 Mamaroneck Avenue, Suite #402, Harrison NY 10528
info@ajfusa.com ● Phone: 1.800.734.9326
Participant Accident Insurance
Quote Request Form
Page 1 of 1
© 2020 Philadelphia Consolidated Holding Corp.
01/2020
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Application - All Other Groups36-10691

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Completed 2 July 2020

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