General Participant Accident Questionnaire

Coverage terms, conditions, limitations and exclusions may vary and may not be available in all states.

Submission Date

Requested Effective Date *

Quote Due Date *

Requested Commission * whole numbers only

Prospective Policyholder Information

Name *

Address *

Physical Address

Address Line 2

City

State

Zip Code

Phone

Website

Term of Coverage Requested: AnnualShort Term

If Short Term, please specify:

Prospective Policyholder Information

Type of Group Camp/ClinicVolunteer GroupNon-Profit OrganizationDay CareCommon CarrierRecreational OrganizationCivic/Fraternal OrganizationAssociationReligious OrganizationOther

If Other, please specify:

Description of Covered Activities (please describe in detail) *

Number of Active Days (Example: # of events, meetings)

Description of Participants *

Number of Total Participants

Number of Participants 12 years & Under

Number of Participants 13-15 years

Number of Participants 16-18 years

Number of Participants 19 years & above

Maximum Age

Benefits Schedule and Principal Sum Amounts

Check all that apply Select AllAccidental Death & Dismemberment*Paralysis**Coma**Accident Medical Expense*Death or dismemberment loss must occur within 365 days of the accident **The Paralysis and Coma principal sum amounts will be the same as the Accidental Death & Dismemberment principal sum selected.Accidental Death & Dismemberment Principal Sum Amount $5,000$10,000$15,000$25,000Other

Accident Medical Expense Benefit Maximum $10,000$15,000$25,000OtherAccident Medical Expense Benefit Type Full Access$100 Primary ExcessPrimary

Accident Medical Expense Deductible Type CorridorVanishing (Integrated)OtherAccident Medical Expense Deductible Amount $0$100$250$500Other

Benefit Period 52 Weeks104 WeeksFirst expense must be incurred within 30 days of the covered accident60 days of the covered accident90 days of the covered accident

Additional requested benefits

Current Coverage

Insurance company

Please attach a copy of the expiring policy. Allowable file types: doc, docx, xls, xlsx, png, pdf, zip, jpgHas the current plan design been the same over the past 5 years? YesNo

If no, please describe the benefit/plan changes from year-to-year in detail:

Please provide the premium and paid loss information for the past five (5) years. Be sure to include the validation date for the paid claim data and attach copies of the carrier loss runs that support the paid claims data.

Policy Year	Premium	Losses Paid	Deductible Amount	Carrier

(Note: The paid loss data should be within 60 days of the Submission Date of this request for proposal)Attach copies of the carrier loss runs that support the paid claims data Allowable file types: doc, docx, xls, xlsx, png, pdf, zip, jpg

Date through which claims are paid

Producer Information

Producer Name *

First

Last

Contact Person

First

Last

Agency Legal Name *

Address *

Street Address

Address Line 2

City

State

Zip Code

Email *

Website

Telephone Number

Fax Number

Note: Business can only be bound, and commission payable, if you and your agency are properly licensed and appointed where required.Terms of Acknowledgement and Signature: This Request for Proposal (RFP) is not a contract of insurance. No coverage is bound or afforded by this RFP. A proposal will be based on information included on and attached to this RFP. The undersigned hereby certifies that this information accurately represents the facts and that no requested information has been misrepresented, misstated, omitted, or altered. In the event that the undersigned becomes aware of facts that would have a material effect on the proposed coverage, any such facts or information will be immediately reported to the carrier. I understand that if information material to the underwriting of this coverage changes, the carrier reserves the right to pursue, without limitation, an adjustment of premiums or coverage, in accordance with such correct facts or information and any other remedies available through operation of law or at equity.Important Notice: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. (Fraud language varies by state, for additional state specific fraud warning language, please click here)

Electronic Signature *

First

Last

Please type your First and Last Name

Your Title

I understand that checking this box constitutes a legal signature confirming that I understand and agree to the above Terms of Acknowledgment.

This is an Accident Only Policy. This is a brief description of coverage provided under policy form series AH51051, underwritten by Berkley Life and Health Insurance Company (domiciled in Iowa - California Certificate of Authority #08527) and/or StarNet Insurance Company (domiciled in Iowa - California Certificate of Authority #6978) 2445 Kuser Road, Suite 201, Hamilton Square, NJ 08690 and is subject to the terms, conditions, limitations and exclusions of the policy. Please see the policy for complete details. Coverage terms, conditions, limitations and exclusions may vary or may not be available in all states. For complete details, please contact us at [email protected]. The insurance described in this document provides limited benefits. Limited benefit plans are insurance products with reduced benefits intended to supplement comprehensive health insurance plans. This insurance is not an alternative to comprehensive coverage. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential coverage as set forth under the Patient Protection and Affordable Care Act.

BAH SR ADMIN 2018-185

Health

Accident

Services

General Participant Accident Questionnaire

General Participant Accident Questionnaire