Individual Sports Instructors Insurance Instant Quote Form Personal Trainers Instant Quote Form If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required Contact Info First Name * Last Name * Address 1 * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Email * Phone How did you hear about us? Select option.... Google Bing Yahoo Friend Other Are you an Insurance Agent? * YesNo Policy Holder Info Name of Policy Holder (Organization Name) * Type of Organization * Select one... Club Corporation Individual Park District Partnership Team Other Policy Holder address information is the same as the Contact Info section above Address 1 * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Coverage Requested Requested Effective Date * Requested Termination Date Activity to be covered * Liability Insurance Per Occurrence Limit * $1,000,000 $2,000,000 or more Aggregate Limit * $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 or more Have you had a liability claim in the past three years? * YesNo If "Yes," please explain Activity and Participant Details Will you have a release waiver on file for each participant? * YesNo If your participants are minors, are parents'/guardians' signatures required for the minors? * YesNoN/A Sport/Activity Age Group Choose one... 9 and under 10-12 13-15 16-18 Adult over 18 # of Participants # of Teams Choose one... 9 and under 10-12 13-15 16-18 Adult over 18 Choose one... 9 and under 10-12 13-15 16-18 Adult over 18 Choose one... 9 and under 10-12 13-15 16-18 Adult over 18 Choose one... 9 and under 10-12 13-15 16-18 Adult over 18 Acceptance of Terms 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.
