Home |  
Quote Request Form

POLICY INFORMATION:

(All the fields marked with * are mandatory)

Name of Group or Organization:*

Street Address:*

City:*

State:*

Zip Code:*

Contact Person:*

Email Address:*

Phone Number (with area code):*

ACTIVITY DETAILS:

Activity:

# of Participants:

Activity:

# of Participants:

Activity:

# of Participants:

Activity:

# of Participants:

Activity:

# of Participants:

SPORTS:

Sport:

# of Participants:

# of Teams:

Sport:

# of Participants:

# of Teams:

Sport:

# of Participants:

# of Teams:

Sport:

# of Participants:

# of Teams:

Sport:

# of Participants:

# of Teams:

# of Participants by Age Group:

12 & under:

13-15:

16-18:

19 & over:

CAMPS:

Sport/Activity:

Day/Overnight:

# of Participants per Week:

# of Participants per Day:

# of Days per Week:

Dates:

FOR SPORT CAMPS ONLY

# of Participants/Week by Age Group:

12 & under:

13-15:

16-18:

19 & over:

COVERAGE DETAILS:

Effective Date:

Expiration Date:

PLAN:

Primary Excess

Full Excess

Primary

LIMITS:

$250,000

$500,000

$1,000,000

 Other  

DEDUCTIBLES:

$0

$25

$50

$100

 Other

To obtain a policy maximum which exceeds $25,000, please provide the following information:

Name of Current Carrier:

Sr. No. Policy Year Premium Losses
Example: 2003 $1,000 $25.00
1.    
2.    
3.    
4.    
No Previous Policy:

Special requests or notes:

Thank you for completing this form.

We look forward to working with you and your special activities.

 

[ Home | Send Email ]

©2004 Macori, Inc.
All Rights Reserved
No part of this web site may be copied or
reproduced without written permission.

Hosted by Host-Central.Net