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 

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Great American Insurance Group

301 E. 4th Street

Cincinnati, OH 45202