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Sun, Sep 7 2008

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Football and Football Cheerleading Insurance - Instant Quote Request

For Amateur Youth and Adult Sports Insurance

Complete the easy quote request below.


Contact Info
Contact Name
Contact Email Address
Phone #   (with area code)
Alternate Phone #   (with area code)
Fax #   (with area code)
How did you hear about us?
Are you an Agent? Check if Yes
PolicyHolder Info
Name of Policyholder
(Organization Name)
Type of Organization
Address
City
State  Zip
Additional Insureds if any
ex. landlord, property owner or other that is required by contract
1. 2.
Name Name
Address Address
City/State/Zip City/State/Zip
Relationship Relationship
3. 4.
Name Name
Address Address
City/State/Zip City/State/Zip
Relationship Relationship
Coverage Requested
Requested Effective Date (MM/DD/YY)
Requested Termination Date (MM/DD/YY)
Activity to be Covered
Accident Medical Insurance
Maximum Medical Expense Benefit  
Accidental Death & Dismemberment Benefit  
Deductible Amount  
Coverage Type Primary Excess
Liability Insurance
Maximum Per Occurrence  
Maximum Per Aggregate  
Activity Details
Enter the Total Number of Players and Cheerleaders     (Complete Section 2)

Section 2 - Football and Cheerleading
Sport or Activity Age Group # Teams/ Squads # Students # Games # Coaches Start Date End Date

I understand and agree that this is only a request for quote and is not an agreement to bind coverage. If quote is agreed upon by both the Agent/Broker and the Insurance Company and payment of the required premium is remitted, coverage will begin on the date premium is remitted or on the effective date indicated above, whichever is later.

By clicking the submit request button, I agree to the above statement.

 




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