Big Brothers BIg Sisters Accident Application

4196 Herschel St Jacksonville, Florida 32210 800-340-4729 904-387-9798 maryw@jlkirby.com

Big Brothers Big Sisters Accident Policy

Thank you for completing this application. It is being returned to John L Kirby & Associates for immediate processing so we may provide your quote. Your progress will be saved at any point, to complete the application at a later time you must restart from the same computer using the same browser. Your data will be saved for a maximum of 5 days. If you have any questions concerning this questionnaire, please call us for help.

Agency Name *

Address *

Address 2

City *

State *

Zip *

Contact Person *

Email *

This insurance coverage will include accident insurance for the community-based children in your program. You also have the option of covering your community-based and site based volunteers.

Limits Available: $5,000 $20,000

Select Limit *

$5,000 $20,000

Do you want to cover your community-based volunteers?

Yes No

Do you want to cover your unmatched/waiting list children?

Yes No

Please provide the current number of unmatched/waiting list children.

Do you want to cover your site/school based children?

Yes No

Do you want to cover your site/school-based volunteers? *

Yes No