Fillable Application - Student Medical Underwriting Questionnaire36-16104

Fill Online, Printable, Fillable, Blank Application - Student Medical Underwriting Questionnaire36-16104 Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application - Student Medical Underwriting Questionnaire36-16104

On average this form takes 7 minutes to complete

The Application - Student Medical Underwriting Questionnaire36-16104 form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 27 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
STUDENT ACCIDENT UNDERWRITING QUESTIONNAIRE
Name of School:
Street Address:
City:
State:
Zip Code:
1.
Number of Enrolled students
Full-Time, Domestic Undergraduate Students:
Graduate Students:
Part-Time Students:
2.
Please provide the rates charged per student for the 4 most recent policy years:
Student
3.
Please provide the number of students covered under the student accident plan for the four (4) most recent
policy years:
Students
4.
In order to provide a quote for the School’s Student Accident Insurance Plan, please also provide
the following:
•
Copies of the school’s current policy.
•
Copies of the claim reports for the four (4) most recent policy years.
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.
Signature: ______________________________________
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
Underwriting Questionnaire
Page 1 of 1
© 2020 Philadelphia Consolidated Holding Corp.
02/2020
Print Application
Clear Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application - Student Medical Underwriting Questionnaire36-16104

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document