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Participant Accident Insurance Request for Quote Form

Client Information

Risk Information

Select a choice
If applicable, please provide the number of participants by age.
Travel To/From:

Desired benefits: 

Select a choice
Maximum Benefit Period

Prior coverage:

is there a plan currently in force?

Producer Information:

Are you a licensed A&H producer in the applicable risk state(s)?
Are you an appointed producer with Great American Insurance Company?

I here by acknowledge that all answers and statements contained on this form are complete and accurate. I also understand that no coverage will become effective until an application has been approved by the Company.  

Please email any attachments to [email protected] 

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Great American Insurance Group

301 E. 4th Street

Cincinnati, OH 45202

[email protected]

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POMI S.M.
Main Office
  • 300 E. Main Street, Suite 314 Charlottesville, VA 22902
  • 1.800.475.2691
Corporate office
  • 301 E 4th St, Cincinnati, OH 45202
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Copyright © 2022 Great American Insurance Group's member companies are subsidiaries of American Financial Group, Inc. (AFG). AFG is a Fortune 500 holding company whose common stock is listed on the New York Stock Exchange. Great American Insurance Company, 301 E. Fourth St., Cincinnati, OH 45202.

Great American Insurance Group