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Accident Insurance Application

QBE Insurance Corporation

Accident Insurance for Lions Clubs

Program Highlights

This plan provides up to $100,000 in Accidental Medical Expense coverage. It protects your members and volunteers who dedicate their time and effort, and it may help reduce your Organization's exposure to liability claims. Details of the program follow.
Accident Medical Expense Benefit Maximum	$100,000 for U&C expenses
Deductible	$0
Benefit Period	52 weeks
Plan Type	Full Excess
Accidental Death Benefit	$25,000
Accidental Dismemberment Benefit Maximum	$50,000
Accidental Paralysis Benefit Maximum	$50,000
Accidental Death, Dismemberment & Paralysis Aggregate Limit of Liability per Accident	$500,000
For important information about the Accident Insurance Program, including a description of the benefits, coverage limitations and exclusions, please connect to the following link: http://www.ajfusa.com/terms/lionsclubplan

Club Information

Participant Information

1. Requested effective date:

2. Total Number of Members and Volunteers per Year:

3. Total Annual Premium (Based on Total Number Of Members and Volunteers):

Up to 125 Members and Volunteers	$300.00	226 to 300 Members and Volunteers	$650.00
126 to 175 Members and Volunteers	$400.00	Over 300 Members and Volunteers - Submit form for quote
176 to 225 Members and Volunteers	$500.00	Over 300 Members and Volunteers - Submit form for quote

Signature

I have read the important information about the Accident Insurance Program provided via the internet Link identified above. The information on this form about our members and volunteers is true and complete to the best of my knowledge. I understand that coverage will not go into effect until this form is received and accepted by the Plan Administrator and the required premium is paid.
Name	Title

Date	Authorized Signature (if submitting paper copy)

To obtain coverage, please return form to

Plan Administrator
The Allen J. Flood Companies
4614 Main St., Suite 2
Lisle, IL 60532

Email
info@ajfusa.com

Phone
800.734.9326 Ext. 248

Fax
914.834.9330

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