Coverage terms, conditions, limitations and exclusions may vary and may not be available in all states.
College/University Name
Physical Address
Street Address
Address Line 2
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
Zip Code
Does your school have an insurance agent or broker? Yes No
If so would you like us to contact them? Yes No
Description of Covered Trip and Travel Party Members Does your organization have a Travel Accident policy that covers injuries occurring outside of the U.S., Canada, and Mexico? Yes No
Sport/Activity
Number of days of athletic competition or practice
Enter the number of Travel Party Members below
Number of Travel Party Members Under Age 18
Number of Travel Party Members Age 18 or Older
Maximum Age
Destination(s)
Length of Stay
How will your Travel Party Members travel to your destination(s) All Travel Party Members on one commercial flight Multiple commercial flights Chartered Aircraft Owned Aircraft Other Please check all that apply.
If “other,” please describe
Terms of Acknowledgement 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 in 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 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.
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 * Please type your First and Last Name.
Title
Date
Consent *
Insurance provided is underwritten by Berkley Life and Health Insurance Company and/or StarNet Insurance Company, both member companies of W. R. Berkley Corporation and both rated A+ (Superior) by A.M. Best. For complete details, please contact Joe Giunta, A-G Administrators, LLC at [email protected]
This is an Accident Only Policy.
This is a brief description of coverage provided under policy form series AH52051, 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.
Travel non-insurance assistance services are not insurance and are provided by a third party vendor.
BAH SR 2019-86Q
