Camp Accident Insurance Application

There was a problem with your submission. Please correct the issues below

Name of Camp *

Contact Name (First/Last) *

Address *

City

State

Zip Code

Email Address

Phone Number

Fax Number

Effective Date of Coverage

Type of group to be covered

Number of Campers

Number of camp days in camp season

Description of Camp Activities

Number of Years in Operation

Are employees/staff included for coverage?

Yes
No

If yes, number of employees

Coverage Plan Desired

Full Excess
Primary

Does the applicant now have this type of coverage?

Yes No

If yes, with whom?

Please provide the premium and loss information for the past four years in the space below

Agent/Broker Name

Agent/Broker Address

Agent/Broker Telephone Number

Policyholder Signature

Policyholder Title

Date

* Required Fields

CAMP ACCIDENT INSURANCE APPLICATION