Fillable Application - Camp Accident Application36-10549

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Application - Camp Accident Application36-10549

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CAMP AND CLINIC ACCIDENT INSURANCE QUOTE REQUEST FORM
Name of Organization:
Contact:
Street Address:
City:
State:
Zip:
Email:
Phone:
Fax:
Start date of camp:
Finish date of camp:
1.
Yes
No
2.
Yes
No
3.
4.
5.
6.
For Sports Camps / Clinics only (Please provide the estimated number of campers per sport, by age group.)
Sport
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
w
ill 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 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:
Street 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
Camp and Clinic Accident Application
Page 1 of 1
© 2020 Philadelphia Consolidated Holding Corp.
01/2020
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Application - Camp Accident Application36-10549

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Completed 2 July 2020

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