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Markel Insurance Company

P.O. Box 2009, Glen Allen, VA 23058-2009

Telephone: (800) 431-1270 Fax: (804) 527-7915

Email applications to: markelah@markelcorp.com

Mailing Address: _____________________________________________________________________________________

County: _____________ State: _____________ Zip Code: ___________ Website: _______________________________

Contact Person & Phone Number: _______________________________________________________________________

Section 1 - General Information

1. Type of school: Community College Trade School (please provide the main types of training, i.e. medical,

masonry, etc.) ___________________________________________________________________________________

2. Total number of students: __________ Number of students under 18 years of age: __________

3. Is Sports Coverage needed? (If yes, complete Section 2) Yes No

4. Total number of athletics? __________

5. Previous Insurance. Indicate premium and losses on accident coverage for the past three years.

6.

Section 2 - Sports Accident Coverage

1. If the school participates in any of the following, please specify the number of participants for each sport.

2. Are student athletes required to have a medical exam before participating in sports? Yes No

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3. Are student athletes required to have a medical exam before returning to sports after an injury? Yes No

without the applicant’s authorization. Credit scoring information may be used to help determine either the applicant’s

eligibility for insurance or the premium the applicant will be charged. The insurer may use a third party in connection with

the development of the applicant’s score. The applicant has the right to review the applicant’s personal information in the

insurer’s files and can request correction of any inaccuracies. A more detailed description of the applicant’s rights and the

insurer’s practices regarding such information is available upon request. Contact the applicant’s agent or broker for

instructions on how to submit a request to the insurer.

Fraud Warning: Any person who knowingly and with intent to defraud any Insurance Company or another person files

an application for insurance or statement of claim containing any materially false information, or conceals for the purpose

of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and

subjects the person to criminal and [NY: substantial] civil penalties. (Not applicable in AL, AR, CO, DC, FL, KS, KY, LA,

to fines and confinement in prison. *Applies in MD Only.

Applicable in CO

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the

purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of

insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,

incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to

defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be

reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Applicable in FL and OK

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal

insurance which such person knows to contain materially false information concerning any fact material thereto; or

conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance

act.

Applicable in KY, NY, OH and PA

Any person who knowingly and with 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 concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such

person to criminal and civil penalties* (not to exceed five thousand dollars and the stated value of the claim for each such

violation)*. *Applies in NY Only.

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Applicable in ME, TN, VA and WA

Applicable in OR

Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an

application containing a false statement as to any material fact may be violating state law.

How did you hear about Markel? Magazine ad Referral Convention/conference Website Other

Describe: ____________________________________________________________________________________________

NOTE: Coverage cannot be bound until the Company approves your completed application. The Company’s receipt of

premium does not bind coverage until a written quote has been issued. Before electronically signing this document, verify

your information is correct. Electronically signing will disable further editing of your application.

Applicant’s signature: ____________________________________________________________ Date: ___________