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If you are part of a national fraternity insurance program, approval of your headquarters office is required, we will request their approval on your behalf. In all cases, issuance of addtional insured protection is at the full discretion of the underwriter. Submission of a request does not automatically grant the requested additional insured protection.
*Fraternity Name:
*Chapter Name:
*Your Name:
*Your Title:
*Your E-Mail Address:
*Is this for: Special Event: Term Policy:
*If for a special event, what is the event?
*What are the dates of the event?
Additional Insured Info
*Name:
*Address:
*City:
*State:
*Zip:
*Phone:
*E-mail:
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