Fillable Intercollegiate Application36-10805

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Intercollegiate Application36-10805

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INTERCOLLEGIATE, CLUB & INTRAMURAL SPORTS ATHLETIC
PARTICIPATION FORM
Name of School:
School Year:
Sport
Number of Players
Indicate Type of Sport
Male
Female
Intercollegiate
Club
Intramural
Archery
Baseball
Basketball
Bowling
Cheerleading
Crew
Cross Country Running
Diving
Equestrian
Fencing
Field Hockey
Football, Tackle - Fall
Football, Tackle - Spring
Football, Tackle / Flag
Golf
Gymnastics
Handball
Ice Hockey
Lacrosse
Martial Arts
Racquetball
Rugby
Sailing
Skiing (downhill)
Skiing (cross-country)
Soccer
Softball
Squash
Swimming
Table Tennis
Tennis
Track & Field
Volleyball
Water Polo
Weightlifting
Wrestling
Other:
Other:
Other:
Intercollegiate Application
Page 1 of 2
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
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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.
Signed:_________________________________________
Title:
Date:
Agent Name:
Agency:
Address:
City:
State:
Zip:
Email:
Phone:
Fax:
Please submit this completed form, a copy of the expiring policy, and currently-dated loss runs for the most recent five
policy years to info@ajfusa.com
Please return form to:
The Allen J. Flood Companies, 2 Madison Avenue, Larchmont, NY 10538
info@ajfusa.com ● Phone: 1-800-734-9326
Intercollegiate Application
Page 2 of 2
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
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Intercollegiate Application36-10805

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Completed 2 July 2020

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