Provident Special Risks Questionnaire

Provident - Main Office:

PO Box 11588

Pittsburgh, PA 15238

Phone: 412.963.1200

Email: benefits@providentins.com

www.providentins.com

Business Hours: 8:30 AM to 5 PM

Please note, this document could take up to 10+ minutes to complete. If you wish to start filling it out now, you can always press "Save & Continue Later" at the bottom of this form to complete and submit at a later time.

NOTE: Coverage is subject to exclusions and limitations and may not be available in all US states and jurisdictions.

Once you have completed this questionnaire, press "Submit" at the end of the form and it will automatically get emailed to reserve@providentins.com. You will receive an email with your entry data and an attached finalized PDF with the data. Thank you for your cooperation!

Please identify who is filling out this Special Risks Questionnaire:*

Submission Date*

Date Proposal(s) Needed*

Requested Coverage Effective Date*

Policyholder Full Name (as it should appear on a policy)*

Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code

Physical Address County*

Mailing Address (check if same as above)

Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState

Zip Code

Mailing Address County

Name of Customer Contact*

Full Name

Customer Phone*

Please enter a valid phone number.

Customer Email Address*

example@example.com

Customer Website

Type of Group*

*If Association, please upload copy of by-laws

Description of Covered Persons*

Describe Activities to be Covered:*

Amount of Exposure - please indicate the # of events, activities, meetings, tournaments, etc. *

Frequency of Exposure*

DailyWeeklyMonthlyAnnually

Total Number of Participants*

By Age:

12 & Under

13-15 years

16-18 years

19 & Above

Maximum Age

Special Risks Questionnaire

CUSTOMER INFORMATION

RISK DATA

EXPOSURE

BENEFITS SCHEDULE

PRIOR COVERAGE

BROKER INFORMATION