Welcome to The Allen J. Flood Companies, Inc. :: Quotations/ Underwriting Forms

	Becoming an AJF Partner
	Product Listing
	Quotations/ Underwriting Forms
	Request For Policy Issue Form

All Fields with (*) are Required

Hospital *

Street Address *

City *

County *

State *

Zip *

Name of person completing this form

First Name *

Last Name *

Telephone Number *

E-Mail Address *

Broker (if applicable)

First Name

Last Name

Broker Address

City

County

State

Zip

Broker Telephone

Please check the box for the coverage Plan you have selected

Plan 1

$2.95 per - Hospital Volunteer and Student Nurse

Plan 2

$3.65 per - Hospital Volunteer and Student Nurse

Plan 3

$5.25 per - Hospital Volunteer and Student Nurse

Coverage For

Desired Effective Date *		(mm/dd/yyyy)
Number of Hospital Volunteers
Number of Student Nurse	+
Total Hospital Volunteers & Student Nurses	=
Rate	x
Annual Premium or $350 whichever is greater	=
Pro-Rata %	x
Premium Due	=

Pro-Rata Table for late enrollment:
Effective Date	Percentage of Premium Payable
July 1	100%
August 1	92%
September 1	83%
October 1	75%
November 1	66%
December 1	58%
January 1	50%
February 1	41%
March 1	33%
April 1	25%
May 1	17%
June 1	8%