Francis L. Dean & Associates
Insurance Application Form

Page 1 of 2

  1. Complete the enrollment form (both pages) in full.
  2. Please make check or money order payable to Francis L Dean & Associates.
  3. Mail your completed enrollment form and premium payment to the address on the second page.
Name of Policyholder
(Last, MI, First) 		___________________________________________________
 
Address of Policyholder
(Address/City/State/Zip) 		___________________________________________________
 
Requested Effective Date ____/____/____/
 
Requested Termination Date __________________
 
Activity to be Covered: (circle one)
Sports Camp
Martial Arts
Dance Studio
Baseball & Softball 		Tackle Football
Youth Sports
Adult Sports
 Day Care
Youth Group
Adult Groups
 Special Events
Boxing & Wrestling
JROTC

Accident Medical Insurance

    Maximum Medical Expense Benefit   $__________________

    Accidental Death & Dismemberment Benefit   $__________________

    Deductible Amount   $__________________


 

Questions? Call us at (800) 745-2409.


Click here for page two.