ITP - Insurance Technologies & Programs, Inc.
A Division of Air Capital Insurance, LLC
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Accident Coverage For Volunteers

Type & Amount of Benefit:

Accidental Death Maximum Benefit $25,000
Accidental Dismemberment Maximum Benefit $25,000
Accidental Medical Expense Maximum Benefit $25,000
Dental Limit Included in Accidental Medical
Expense Benefit Deductible Amount
$0

Name of Insured: (Sponsoring Organization)

Street Address:

City:

State:

Zip:

Name of Event:

Dates of Coverage:

Select Date

Select Date

Activities to Be Covered: (be specific)

Type of Event: How Often Held: # of Volunteers: Ages:

Are supervisors included in the above number of volunteers?

What experience do the volunteers and supervisors have in the activities to be covered? If similar accident coverage has been carried in the past, give details.

Policy Year:   2013   2014
Premium: $ $

Contact Name:

Phone:

Fax:

Email:

Please enter any additional info below:

 
INSURANCE TECHNOLOGIES & PROGRAMS
(A Division of Air Capital Insurance, LLC)
P.O. Box 148 - Wichita, KS 67201
For Overnight Payments: 127 E. 2nd St - Wichita, KS 67202
Toll Free: (866) 585-4590 - Phone: (316) 303-1272 - Fax: (316) 491-2245
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