Fillable Application - K-12 Accident36-10669

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Application - K-12 Accident36-10669

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STUDENT ACCIDENT INSURANCE QUOTE REQUEST FORM
School Name:
School Contact:
Address:
City:
State:
Zip:
Email:
Phone:
Fax:
Requested Effective Date of Coverage:
1.
Yes
No
2.
Yes
No
3.
Grades
Student Enrollment
Pre-K – 8
9 - 12
4.
Yes No
5.
Current Year
20 20 20 20
Premium
Paid Claims
As of Date
Insurance Carrier
Request for Quote:
Please provide a Student Accident Insurance quote based on the information provided on this form and any attachments.
To the best of my knowledge, all information provided is complete and accurate.
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:
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
Student Accident Insurance
Quote Request Form
Page 1 of 1
© 2020 Philadelphia Consolidated Holding Corp.
01/2020
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Completed 2 July 2020

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