National Provider of Sports & Entertainment Insurance

 

13100 Shire Lane    Fort Myers, FL    33912

 (888) 288-1829 tel (630) 393-5666 fax

info@dhcins.com

 

HOME PROGRAMS FAQ & LINKS CONTACT

Camp & Conference Accident and Liability Insurance Program Application

 * = required field

Name of Camp/Clinic*  

Email*

   Fax 999-999-9999

Street Address*  
City*    State     Zip Code  
Phone*    999-999-9999
Policy Term*    (You must choose one for an accurate calculation of Premium.)
Effective Date of Coverage*    Termination Date of Coverage
Please list all sports & activities*  

Has prior coverage been cancelled or non-renewed?*

 

Do you currently utilize a waiver system?*  
Do you currently have a Risk Management Plan?*  

Premium Rates

Total number of Day Campers (1 Day Policy Term)

 

at

$2.50 / pp

Total number of Day Campers (2 Day Policy Term)

 

at

$2.75 / pp

Total number of Day Campers (3 Day Policy Term)

 

at

$2.75 / pp

Total number of Day Campers (4+ Day Policy Term)

 

at

$3.50 / pp

Total number of Overnight Campers

 

at

$4.50 / pp

Total number of Coaches

 

at

$2.00 / pp

Optional Hired/Non-Owned Auto Coverage

 

at

$850.00

 

 

  **

 

** Please note:  Minimum Program Premium is $362.50 for policies with less than annual terms and $415.00 for Annual Policies.  The Minimum Premium does not include the optional hired and non-owned automobile liability coverage.  The Premium amount calculated above will be verified by DHC Insurance.

 

 

List any Additional Insured and relation to the applicant:

Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits application of files claim containing a false or deceptive statement may be guilty of insurance fraud.  Minimum premiums are fully earned.

 

Authorized Electronic Signature*:
Title or Position:
   
 

 

 

 


DHC is a USA company and can not provide coverage outside of the USA.

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13100 Shire Lane   |   Fort Myers, FL   |   33912   |  (888) 288-1829 tel   (630) 393-5666 fax

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