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Accident Insurance Application

Accident Insurance Application

Accident Insurance for Lions Clubs

All fields are required. Use N/A if not applicable.

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

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Club Information


Participant Information

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





Signature


Please Enter This Security Code Below: twoeightonethreeeight


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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