Fillable Application - Amateur Sports - Accident Application36-9983

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Application - Amateur Sports - Accident Application36-9983

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AMATEUR SPORTS / ACTIVITIES 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.
For activities other than sports, please provide a brief description of activities to be covered:
3.
Estimated Number of Participants By Sport or Activity
Number of Participants By Age Group
Sport or Activity
Duration of Activity
9 & Under
10 - 12
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
c
ompany 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
w
ill form part of any policy issued, (b) no information given to or acquired by any representative of Philadelphi
a
I
ndemnity 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 Insuranc
e
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
Amateur Sports - Activities Accident Insurance
Quote Request Form
Page 1 of 1
© 2020 Philadelphia Consolidated Holding Corp.
01/2020
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Application - Amateur Sports - Accident Application36-9983

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Completed 2 July 2020

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