Amateur Sports / Activities Accident Insurance Quote Request Form (Philadelphia Insurance Companies) Instructions

Enter the job title, role, or capacity of the person signing the acknowledgement (e.g., President, Treasurer, Authorized Representative).

Enter the date when the acknowledgement was signed by the person identified in the Title field.

Enter a brief description of the activities to be covered (for activities other than sports).

Enter the full name of the insurance agent representing the applicant.

Enter the name of the agent's agency or firm.

Enter the street address for the agent or agency.

Enter the city for the agent's address.

Enter the state for the agent's address.

Enter the postal ZIP code for the agent's address.

Enter the agent's email address for contact and correspondence.

Enter the agent's primary contact phone number, including area code.

Enter the agent's fax number if available.

Check this box if the organization currently has accident insurance coverage (if checked, submit a copy of the expiring policy and currently-dated loss runs for the most recent five policy years).

Check this box if the organization does not currently have accident insurance coverage.

Enter the name of the sport or activity for this row (for example, 'Soccer', 'Art Class', or 'Basketball').

Enter the typical duration or frequency of the activity for this row (for example, '2 hours', 'seasonal', or 'weekly'). Fill only if 'Row 1 - Sport or Activity' is filled.

Enter the estimated number of participants aged 9 and under who participate in this activity. Fill only if 'Row 1 - Sport or Activity' is filled.

Enter the estimated number of participants aged 10 to 12 who participate in this activity. Fill only if 'Row 1 - Sport or Activity' is filled.

Enter the estimated number of participants aged 13 to 15 who participate in this activity. Fill only if 'Row 1 - Sport or Activity' is filled.

Enter the estimated number of participants aged 16 to 18 who participate in this activity. Fill only if 'Row 1 - Sport or Activity' is filled.

Enter the estimated number of participants over age 18 who participate in this activity. Fill only if 'Row 1 - Sport or Activity' is filled.

Enter the name of the sport or activity for this row (for example, 'Soccer', 'Gymnastics', or 'Summer Camp').

Enter the duration or seasonality of the activity for this entry (for example, '3 months', 'Weekly - 2 hours', or 'June–August'). Fill only if 'Row 2 - Sport or Activity' is filled.

Provide the estimated number of participants aged 9 and under who will participate in this activity. Fill only if 'Row 2 - Sport or Activity' is filled.

Provide the estimated number of participants aged 10 to 12 who will participate in this activity. Fill only if 'Row 2 - Sport or Activity' is filled.

Provide the estimated number of participants aged 13 to 15 who will participate in this activity. Fill only if 'Row 2 - Sport or Activity' is filled.

Provide the estimated number of participants aged 16 to 18 who will participate in this activity. Fill only if 'Row 2 - Sport or Activity' is filled.

Provide the estimated number of participants aged over 18 who will participate in this activity. Fill only if 'Row 2 - Sport or Activity' is filled.

Enter the name of the sport or activity for row 3 (for example: Soccer, Basketball, Swim Team).

Enter the typical duration or frequency of the activity for row 3 (for example: 2 hours per session, seasonal, weekly). Fill only if 'Row 3 - Sport or Activity' is filled.

Enter the estimated number of participants age 9 and under for this activity in row 3. Fill only if 'Row 3 - Sport or Activity' is filled.

Enter the estimated number of participants ages 10–12 for this activity in row 3. Fill only if 'Row 3 - Sport or Activity' is filled.

Enter the estimated number of participants ages 13–15 for this activity in row 3. Fill only if 'Row 3 - Sport or Activity' is filled.

Enter the estimated number of participants ages 16–18 for this activity in row 3. Fill only if 'Row 3 - Sport or Activity' is filled.

Enter the estimated number of participants over age 18 for this activity in row 3. Fill only if 'Row 3 - Sport or Activity' is filled.

Enter the name of the sport or activity for row 4 (for example, Soccer, Basketball, or Swimming).

Provide the typical duration or season of the activity for row 4 (for example, '6 weeks', 'Seasonal', or 'Per session'). Fill only if 'Row 4 - Sport or Activity' is filled.

Enter the estimated number of participants aged 9 and under for this sport/activity in row 4. Fill only if 'Row 4 - Sport or Activity' is filled.

Enter the estimated number of participants aged 10 to 12 for this sport/activity in row 4. Fill only if 'Row 4 - Sport or Activity' is filled.

Enter the estimated number of participants aged 13 to 15 for this sport/activity in row 4. Fill only if 'Row 4 - Sport or Activity' is filled.

Enter the estimated number of participants aged 16 to 18 for this sport/activity in row 4. Fill only if 'Row 4 - Sport or Activity' is filled.

Enter the estimated number of participants over age 18 for this sport/activity in row 4. Fill only if 'Row 4 - Sport or Activity' is filled.

Enter the name of the sport or activity corresponding to row 5.

Enter the duration, season, or frequency of the activity for row 5 (for example: 'Weekly', 'Summer season', '2 hours'). Fill only if 'Row 5 - Sport or Activity' is filled.

Enter the estimated number of participants aged 9 and under for the activity listed in row 5. Fill only if 'Row 5 - Sport or Activity' is filled.

Enter the estimated number of participants aged 10 to 12 for the activity listed in row 5. Fill only if 'Row 5 - Sport or Activity' is filled.

Enter the estimated number of participants aged 13 to 15 for the activity listed in row 5. Fill only if 'Row 5 - Sport or Activity' is filled.

Enter the estimated number of participants aged 16 to 18 for the activity listed in row 5. Fill only if 'Row 5 - Sport or Activity' is filled.

Enter the estimated number of participants over age 18 for the activity listed in row 5. Fill only if 'Row 5 - Sport or Activity' is filled.

Enter the name of the sport or activity for this row (for example: Soccer, Basketball, Summer Camp, Dance).

Enter the typical duration or frequency of the activity (for example: 'Season', 'Weekly - 2 hrs', '6-week session'). Fill only if 'Row 6 - Sport or Activity' is filled.

Enter the estimated number of participants age 9 and under who will take part in this sport or activity. Fill only if 'Row 6 - Sport or Activity' is filled.

Enter the estimated number of participants ages 10 to 12 who will take part in this sport or activity. Fill only if 'Row 6 - Sport or Activity' is filled.

Enter the estimated number of participants ages 13 to 15 who will take part in this sport or activity. Fill only if 'Row 6 - Sport or Activity' is filled.

Enter the estimated number of participants ages 16 to 18 who will take part in this sport or activity. Fill only if 'Row 6 - Sport or Activity' is filled.

Enter the estimated number of participants over age 18 who will take part in this sport or activity. Fill only if 'Row 6 - Sport or Activity' is filled.

Enter the full legal or commonly used name of the organization requesting the insurance quote.

Enter the organization's street address, including building, suite or unit number if applicable.

Enter the city where the organization's street address is located.

Enter the state or province for the organization's address (commonly a two-letter abbreviation).

Enter the ZIP or postal code for the organization's mailing address.

Enter the full name of the primary contact person for this organization.

Enter the primary contact's email address for correspondence about the quote request.

Enter the primary contact's daytime phone number, including area code and any extension if applicable.

Enter the organization's fax number if available, or leave blank if none.

Enter the date on which you want the insurance coverage to begin.