Medical Insurance Application

*Required
Company Information			Paper Version
Company Name
First Name*
Last Name*
Address*
City*
State*
Zip*
Daytime Telephone Number*
Mobile Telephone Number
Fax Number
Your Email Address*
Your Website Address
Years Experience*
Desired Policy Limit
Underwriting Information
Desired Effective Date*
Desired Expiration Date*
Type of Business / Activity*
Number of Daily Participants
Number of Daily Volunteers
Number of Daily Staff
Number of Daily Spectators
Number of Activity Days
Name of Location*
Location Address *
City*
State*
Zip*
Telephone Number
Fax Number
Contact Person (First & Last Name)
Contact Person Email Address
Describe Your Activities in Detail*
Who was your previous insurance company*
Premium paid*
List all previous claims (Last 5 years)*
Application Warranty & Instructions I HEREBY WARRANT AND CONFIRM THAT THE ABOVE INFORMATION, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, AND FURTHER CERTIFY THAT I HAVE READ ALL OF THE QUESTIONS AND ANSWERS OF THIS APPLICATION. I UNDERSTAND THIS APPLICATION IS A REQUIREMENT FOR COVERAGE, A PART OF THE CONTRACT AND EVIDENCE OF MY ACCEPTANCE OF THIS INSURANCE, AND ANY FALSIFICATION OR MISREPRESENTATION WILL BE DEEMED A BREACH OF CONTRACT, VOIDING ALL INSURANCE COVERAGE. IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL NOT BE BINDING EITHER TO THE PROPOSED INSURED OR THE COMPANY UNTIL ACCEPTED BY THE COMPANY OR COMPANIES IN WRITING.
Name of person acknowledging Warranty*
Date of acknowledgment*
For Insurance Agents & Brokers Only
Your Company Name
First Name
Last Name
Address
City
State
Zip
Daytime Telephone Number
Mobile Telephone Number
Fax Number
Your Email Address