Activities:

Activity: # of participants:
Activity: # of participants:
Activity: # of participants:
Activity: # of participants:
Activity: # of participants:
Activity: # of participants:

Sports:

Sport: # of participants: # of teams
Sport: # of participants: # of teams
Sport: # of participants: # of teams
Sport: # of participants: # of teams
Sport: # of participants: # of teams
Sport: # of participants: # of teams

# of participants by age group:
12 & under   13-15    16-18    19 & over

Camps:

Sport/Activity:
Day/Overnight:
# of Participants/Week:
# of Participants/Day:
# of Days/Week:
Dates:

For Sport Camps ONLY:

    # of participants/week by age group:
    12 & under   13-15    16-18    19 & over

Effective Date: Expiration Date:

Plan:
        Primary Excess   Full Excess   Primary

Limits:
        $250,000     $500,000     Other $

Deductibles:
        $0       $25       $50       $100       Other $

For accounts over $25,000, please provide:

Name of Current Carrier:

If you would like us to work with your local agent, please provide name and telephone number:

Agent Name: Phone #: