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Participant Accident Insurance Request for Quote Form

Requested Effective Date of Coverage

Quote Due Date

Client Information

Company

Name

Email

Address

City

State

Zip

Website

Risk Information

Select a choice

Camps
Non-Profits
Childcare
After School Activities
Youth Sports
Health + Fitness
K-12 Schools
Collegiate Activities
Special Events
Other... This choice will expand a text box

If sports is checked above, please list which sports:

Day Participants

Overnight Participants

Total Number of Participants

If applicable, please provide the number of participants by age.

12 and Under:

13-15:

16-18

19 and Older:

Maximum Age

Description of covered persons (who is to be covered)

Describe covered activities

Travel To/From:

Yes
No

Desired benefits:

Accidental Death

Accidental Dismemberment

Accidental Paralysis

Accidental Medical Expense

Select a choice

Excess
Primary

Maximum Benefit Period

52 weeks
104 weeks

Other Benefits Requested:

Aggregate limit per occurrence (standard is 10 times the Accidental Death benefit)

Prior coverage:

is there a plan currently in force?

Yes
No

If yes, please provide carrier name:

Effective date

Producer Information:

Name of agency

Contact

Address

City

State

Zip

Phone

Email

Requested commission: 15% is standard

Are you a licensed A&H producer in the applicable risk state(s)?

Yes
No

Are you an appointed producer with Great American Insurance Company?

Yes
No

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 underwriting@getpomi.com.

Initial to agree to the above statement.

Date

New code

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Great American Insurance Group

301 E. 4th Street

Cincinnati, OH 45202

underwriting@getpomi.com

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.