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Texas Location:
307 West 7th Street, Suite 1720
Fort Worth, TX. 76102
Phone: (817) 810-0507
FAX (817) 810-0477
Phone: (800) 375-0552

Sports and Non-Sports Camp, Clinic or Tournament Policy Application Form

This form is for submitting your application online.
If you would like to mail or fax your application to us, please click here.

* = Required information

Name of Camp/Clinic   *
Street Address   *
City   *
State   *  Zip Code *
Phone #   (with area code)
Policyholder Email Address  
Requested Effective Date   (MM/DD/YY) *
Requested Termination Date   (MM/DD/YY) *

Camp Clinic is

   Day Only
Overnight

Description of Activity:

    

Premium Information:

Number of Participants: 
To Review The Premium Rates Please View http://athletic-insurance.com/sports_camp_insurance.html

Hired and non-owned automobile coverage ($850.00)

Payment Information

Pay online with Credit Card (Visa, Mastercard, or American Express
     Name on Credit Card
      
     Credit Card Number      
     Expiration Date       (00/00)

Call Me for Credit Card Info

I want to pay 20% and finance the balance.
      Please send finance agreement and information.

Insuring Agreement

I understand and agree that if this application is accepted by the Company, coverage will begin on the date of acceptance or on the date requested, whichever is later, subject to the payment of the required premium.

I understand that the premium is fully earned upon policy inception.

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits application of files containing a false or deceptive statement is guilty of insurance fraud.

Type your name below, to indicate that you have read and accepted the terms above:

*

When you are ready to verify your application, click on "Proceed" below. Please note that by clicking on "Proceed" below you are purchasing this insurance coverage.



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Texas Location
307 West 7th Street, Suite 1720
Fort Worth, TX. 76102
Phone: (817) 810-0507
FAX (817) 810-0477
Phone: (800) 375-0552

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