Fillable Application - Student Underwriting Questionnaire36-11308

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Application - Student Underwriting Questionnaire36-11308

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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 i
n
w
riting 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.
01/2020
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Completed 2 July 2020

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