Camp Insurance Request Form - Offline Payment

Fields marked with an asterisk (*) are required.

Camp Information

* Dates of Coverage: —
* Is this an All-Star Camp?
* Is the All-Star Camp sanctioned by your state's coaches association?
* Is this an overnight camp?
* Do you have a signed waiver in place that shows indemnification language?
* Do you have Participant/Accident coverage in place?

* Coverage Information for Participant/Accident (Medical)

* Coverage Information for Participant/Accident (Medical)

Maximum Accident Medical Benefit: $25,000 | Accidental Death $5,000 | Deductible: $500

Please note that Participant/Accident (Medical) coverage is mandatory.

Note: The total # of days refers to the actual participation days

Sport # of
Participants per day		 # of Coaches/
Volunteers		 # of
Days		 Remove

Camp Venue Information

Add at least one venue for this camp.

Certificate Holder Information

A certificate holder is the entity requesting proof of insurance from you.

* Is the certificate holder the same as the Location (Venue)?

Additional Insured Information

An additional insured is the certificate holder requiring additional insured status.

* Do you need to add an Additional Insured?

Your Information

Payment Information

(Note: if you are mailing a paper check, please make it out to "Loomis & LaPann, Inc." and an invoice will be emailed to the email address listed under "Your Information" above.)
(Note: coverage is void if an All-Star Camp is not sanctioned by your state's coaches association.)