Name of Group *
Street Address *
City *
County *
State *
Zip *
Name of individual completing this form. *
First Name *
Last Name *
Telephone number of individual completing this form. *
E-mail address of individual completing this form. *
How many weeks will the camp operate? *
What is the estimated number of campers per week? *
Is the camp a day camp or a residential camp? *
Is the camp an educational/recreational camp or is it specifically designed for sports instruction? *
If the camp is specifically designed for sports instruction, please also provide the following information:
The pricing for sports teams & leagues, town recreation programs, YMCA's and similar risks is determined by the number of participants and the ages of the participants; therefore, we need the following information:
Has the organization had accident insurance coverage in the past? * If yes, then:
What is the Accident Medical Expense limit?
Provide the premium and claims paid information for the past four years beginning with the current year:
Home 
Contact Us 
Site Map 
