Starr Indemnity & Liability Co Form

NOTICE

WARNING: Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information converning any fact material thereto, commits a fraudulent insurance act, which may be a crime

PART A - This PART must be completed by an official or the Organization

First Name
Required

Last Name
Required

E-Mail Address
Required

Policy Number
Required

Name of Organization or Team (if different from Policyholder)
Optional

City
Required

State
Required

select

ZIP / Postal Code
Required

Name of Injured Person (Insured)
Optional

Date of Accident/Injury
Required

Open the calendar popup.

Injury Occurred:
Optional

Practice

Travel

Game

Other

Type of Sport or Activity
Optional

Explain HOW the accident and injury occurred
Optional

Describe the nature of injury.
Optional

At the time of the accident, was the Injured Person involved in an activity under the jurisdiction of the Organization (Policyholder)?
Optional

Yes

Name of Supervisor of Activity
Optional

Was he/she a witness
Optional

Yes

Name of Organization Official
Optional

Title of Official
Optional

Area Code/Telephone No
Optional

Enter Validation Code

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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