Loomis & LaPann, Inc. - We Are Sports Insurance

If you have any questions or issues filling out the form below, please contact us at 800-566-6479.

Please allow up to 7 business days for processing. If you do not receive correspondence from us after 7
business days, please contact us.

Camp Information

* Coverage Information for Participant/Accident (Medical)

* Name of Insurance Carrier:

* Policy Number:

* Expiration Date:

* Policy Limit:

* Policy Deductible:

* Coverage Information for Participant/Accident (Medical)

Maximum Accident Medical Benefit: $25,000 | Accidental Death $5,000 | Deductible: $500

Please note that Participant/Accident (Medical) coverage is mandatory.

Note: The total # of days refers to the actual participation days

Sport	# of Participants per day	# of Coaches/ Volunteers	# of Days	Remove

Camp Venue Information

* Name of Venue:

* Venue Street Address:

* Venue City:

* Venue State:

* Venue Zip:

* Venue Contact Person:

Venue Contact Phone Number:

Venue Contact Email Address:

Venue Contact Fax Number:

Certificate Holder Information

A certificate holder is the entity requesting proof of insurance from you.

* Is the certificate holder the same as the Location (Venue)? No Yes

Additional Insured Information

An additional insured is the certificate holder requiring additional insured status.

* Do you need to add an Additional Insured? No Yes

Your Information

* Your First Name:

* Your Last Name:

* Email Address:

* Phone Number:

Fax Number:

* Street Address:

* City:

* State:

* Zip:

Payment Information

Your Total Premium (plus additional fees, not including transaction fees): (Note: if you are mailing a paper check, please make it out to "Loomis & LaPann, Inc.")

I certify that I am a current member in good standing with my state's coaches association. (Note: coverage is void if an All-Star Camp is not sanctioned by your state's coaches association.)

* Verification:

	(800) 566-6479
	(518) 792-3426
	sports@loomislapann.com
	228 Glen Street, P.O. Box 2158 Glens Falls, NY 12801

Camp Insurance Request Form - Offline Payment

Camp Information

* Coverage Information for Participant/Accident (Medical)

* Coverage Information for Participant/Accident (Medical)

Camp Venue Information

Certificate Holder Information

Additional Insured Information

Your Information

Payment Information

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