Name of School or District

Address:

Contact Name/Title:

Grades Included

Full Excess
Primary

Effective Date:

Expiration Date:

School Time Rate:

24 Hour Rate:

Full Excess. Please indicate activities currently covered:
High School Sports
High School Football
Junior High Sports
Junior High Football
Band, Cheerleaders, Majorettes
Gym
Intramurals
Non-Sports Extra Curricular
Other

Effective Date:

Expiration Date:

Total Premium:

(Include Premium from any separate catastrophic policy in Total Premium)