ACCIDENT INSURANCE PROGRAM
SPORTS AND ACTIVITIES

(NAME OF GROUP)_____________________________________________ hereby applies for participation in the SPECIAL RISK ACCIDENT AND SICKNESS TRUST and agrees to be bound by the terms and conditions of the Trust Agreement.

Address: _________________________________________________________

City:        ________________________State: ___________ Zip: ______________

Telephone: (       )_____-___________                 FAX: (       )_____-_____________

BASE EXCESS MEDICAL COVERAGE
Effective Date: ____________                             Expiration Date: _____________

Maximum Medical Benefit $_______________ Deductible $______________
      

        Full Excess No Deductible (       )             Primary Excess over $100.00 (       )

SPORT OR ACTIVITY AGE GROUP NO. OF PARTICIPANTS PREMIUM
       
       
       
       
       
Name and Title of authorized
representatives (please print)______________________________________________

Signature of Auth. Rep.___________________________________ Date: ___________

Agent or Broker: ________________________________________________________