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Name of Organization *

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

# of Members/Participants

Age Range of Members/Participants

Description of Activities

Number of Years in Operation

Coverage Plan Desired

Full Excess
Primary

Does the applicant now have this type of coverage?

Yes No

If yes, with whom?

Estimated Number of Participant by Activity

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

General Accident Application