1Contact & Coverage Information2Liability Questionnaire3Additional Information & Digital Signature Policy Holder InformationOrganization Name*As it will appear on Policy Documents. Email* Contact First Name* Contact Last Name* Phone*Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Coverage DetailsName of Camp / Clinic* Desired Effective Date*Camp and Clinic session dates will be obtained later in the application process. MM slash DD slash YYYY Desired Expiration Date* MM slash DD slash YYYY List all non-sport activities offered at camp/clinic:*Non-sports Only. Use the + button for multiple activities. List all sports activities to be covered at camp/clinic:*Sports Only. Use the + button for multiple activities Describe a typical camp session. What will the participants be doing during the covered camp/clinic?PLEASE NOTE: Before/After School Programs, Camps with Horseback Riding, Camps with Amusement Park or Water Park exposures, Sport Instruction Facilities & Adult Soccer Tournaments are excluded unless approved by carrier. Additional underwriting will apply. PLEASE NOTE INELIGIBLE ACTIVITY TYPES: High Ropes Courses, Zip Lines, Trampolines, Mechanical Bulls, Rock Climbing, Firearms/Riflery, White Water Rafting, Gymnastics, Jet Skis, Motorized Boats, ATVs, Water Skiing/Boarding, Fire Dancing, Bungee Jumping and Activities outside of the U.S. are not eligible for coverage. How many camp sessions do you want to cover?*Please enter the details for each individual camp or clinic session seperately.Use the + button to add more Camp / Clinic entries.Camp / ClinicDateDurationNumber of Youth ParticipantsNumber of Adult Participants Does your camp/clinic participants staying overnight?:* Yes No Please describe: Liability QuestionnaireDo you utilize a waiver system?*Click here if you need a copy of a waiver. Yes No Do you have a Risk Management Plan?*If you do not yet have such a plan in place, please click here for our Guide to Risk Management. Yes No Has prior coverage been cancelled or non-renewed?* Yes No Please Describe*Liability Insurance Limit Requested* $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Accident Medical Limits Requested*A minimum accident limit of $10,000 is required if participant liability coverage is desired. None $10,000.00 $25,000.00 $50,000.00 $100,000.00 Select Accidental Medical DeductibleCheck deductible option(s) you would like included in your quote. $100 $250 $500 $1,000 $2,500 Additional InsuredAdditional Insured 1 Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship Additional Insured 2 Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship Additional InformationHow did you hear about us?* Optional Coverage's (Premiums are fully earned at inception)Hired and Non-Owned Automobile Liability Coverage$1,000,000.00 Hired and Non-Owned Automobile Liability Coverage is available but subject to additional underwriting. Please contact your agent if wishing to apply for coverage. None $150,000 Limit (additional premium = $225.00) $500,000 Limit (additional premium = $500.00) Sexual Abuse and Molestation Liability Coverage None $100,000 Limit (additional premium = $1,000.00) Medical Expense BenefitMedical Expense Coverage pays for costs incurred by an individual on your premise who is not an athletic participant (i.e. parent of child, postal service worker, etc.) regardless of who is at fault. None $5,000 Limit (additional premium = $5,000) Equipment CoverageEquipment Coverage is available but subject to additional underwriting. To request a quote, please submit an online application. The following link will take you to the Equipment Coverage Application: Equipment Coverage Acknowledgement & SignaturesAny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not in force until accepted by Anthony Insurance Services, Inc. Coverage is subject to the receipt of payment of the required premium by Anthony Insurance Services, Inc. Coverage will begin on the date of acceptance or on the date requested, whichever is later. I understand that the premium is fully earned upon policy inception.Authorized Electronic Signature* Δ
