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University/College:
Address:
City:
State:
Zip:
Contact:
(For purposes of
this insurance)
Address:
City:
State:
Zip:
Work Phone:

Cell Phone:

Fax:

E-mail:

Greek Advisor:
UNDERWRITING INFORMATION

Groups to be covered:
(check all that apply)

If other, please specify:

Please answer the question(s) which apply, depending on the groups seeking coverage
Total # of sororities at University
Total membership
# of sororities that are housed
  
  
Total # of fraternities at University
Total membership
# of fraternities that are housed
Please choose the activities that the group seeking coverage participate in/sponsor
Yes
No
  
Peer Monitoring
(If so, please answer questions A and B.)
   
A. (Please choose one)
B. Do monitors receive any form of training prior to serving as monitors?
Sponsor Rush Activities
Sponsor Homecoming Activities
Sponsor Greek Week Activities
Does a Greek Judicial or similar Board exist that is responsible for the enforcement of University/Greek policies and rules?
Yes
No
Are you involved in the registering or approving of fraternity and sorority functions?
Yes
No
Please give information on any known liability claims in the past 5 years:
Date of Incident
Type of Loss
Description of Incident
Amount Paid

Do you have a current loss run from your property insurance carrier?  
Your name:
Your title:
Your e-mail address:
Your work phone:
(i.e. 222-222-2222)
Your cell phone:
(i.e. 222-222-2222)
Your fax phone:
(i.e. 222-222-2222)
Today's date:
(i.e. MM/DD/YY)
   
 
 
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