Special Risk Division Activity Report Form

To send us your activity report for upcoming events, fill out the form below. Please choose your organization type before entering your information. When finished, click “Submit” at the bottom of the page.

All group participants must be included for coverage.

Have questions? Visit our FAQ section.

If you have any issues with this form, please contact specialrisk@ailife.com. Our agents are available each weekday from 8:30am to 5:00pm Eastern. We respond to emails within one to two business days.

Organization Type

Policy Number * Policy Number is required. Exceeds the maximum number of characters allowed.

Organization * Organization is required. Exceeds the maximum number of characters allowed.

Contact First Name * First Name is required. Exceeds the maximum number of characters allowed.

Contact Last Name * Last Name is required. Exceeds the maximum number of characters allowed.

Group Name * Group Name is required. Exceeds the maximum number of characters allowed.

Phone Number * Phone Number is required. Exceeds the maximum number of characters allowed.

Email * Email is required. Exceeds the maximum number of characters allowed. Please enter a valid email address.

Mailing Address * Address is required. Exceeds the maximum number of characters allowed.

Mailing Address 2 Exceeds the maximum number of characters allowed.

City * City is required. Exceeds the maximum number of characters allowed.

State * State is required.

ZIP Code * Zip is required.

County * County is required. Exceeds the maximum number of characters allowed.

Comments

At least one activity must be filled out below.

Activity Description * Description is required. Exceeds the maximum number of characters allowed.

Start Date * Start Date is required.
Please enter a valid date.

End Date * End Date is required.
Please enter a valid date.
End Date must be after the Start Date.

# of Daily Participants * Participants is required. Exceeds the maximum number of characters allowed.

Rate * Rate is required.

FAQ

Who is covered by the Special Activities Policies?

AIL Special Risk Division policies are for youth, adult participants, and volunteers. Coverage is not provided for spectators or members of the general public. We provide blanket policies, which means that all participants must be included on the activity report. Use your best estimate of participants when you submit your report, and afterwards use the actual number to calculate the premium due.

Are there any age restrictions?

The AIL Special Risk Division does not insure people less than age 5 for any activity.

Is it too late to request activity coverage?

You may request coverage anytime before the first event (up to a day before); however, you must submit your activity report before the event(s) begin. While denials are rare, we do like the opportunity to review each request in advance of your events so that we can identify any potential problems and contact you with questions if needed.

I accidentally submitted a duplicate request for coverage. Can you delete it?

Please email both serial numbers to specialrisk@ailife.com, and indicate which is the correct/active coverage request. We will delete the duplicate request from our records.

Does blanket accident medical coverage only help individuals without insurance?

Any covered individual who is injured or ill will face out-of-pocket medical expenses. Our benefits can be applied toward deductibles, copayment requirements, and expenses in excess of personal insurance limits.

We are a 4-H/CES group with an annual policy. When do we use the special activities coverage?

If you have an annual policy for your 4-H/Extension group, there are situations where it is wise to purchase special activities coverage:

Resident camps and other overnight travel outside the county
Downhill winter sports (skiing, snowboarding, tubing), which are excluded by the annual policy
Guests and other participants in events sponsored by 4-H/Extension who are not enrolled in your program.

My organization no longer writes checks. What are the other payment options?

We understand that you many have several different funding streams or ways of processing payments. If you are unable to submit a check request in a traditional way, some options to consider may be to purchase orders or check requests from your affiliated university. If none of these options are available to you, please contact our office so that we can assist.

Do you offer liability insurance?

No. Blanket accident and illness policies from AIL Special Risk Division are not liability insurance.

What groups and events are eligible for insurance from AIL Special Risk Divison?

If you’re not sure whether your group or event meets our requirements to be insured, please feel free to contact us. We are available by phone each weekday from 8:30am-5:00pm Eastern, and we respond to emails within one to two business days. Get in touch via email.

Thank you!

We have received your application. For further inquiries, contact us.

Please review your information below:

Contact First Name: {{vm.contact.firstname}}

Contact Last Name: {{vm.contact.lastname}}

Phone: {{vm.contact.phone}}

Email: {{vm.contact.email}}

Organization Name: {{vm.contact.organizationname}}

Group Name: {{vm.contact.groupname}}

Policy Number: {{vm.contact.policynumber}}

Mailing Address: {{vm.contact.address1}}

Mailing Address 2: {{vm.contact.address2}}

City: {{vm.contact.city}}

State: {{vm.contact.statecode}}

Zipcode: {{vm.contact.zipcode}}

County: {{vm.contact.county}}

Comments: {{vm.contact.comments}}

Description: {{activity.description}}

Start Date: {{activity.startdate}}

End Date: {{activity.enddate}}

Number of Participants: {{activity.numberofparticipants}}

Rate: {{activity.rate}}

Benefits	Plan A 20¢ person / day covers up to:	Plan B 25¢ person /day covers up to:	Plan C 30¢ person / day covers up to:
Medical / surgical treatment, including: X-ray examinations Hospital confinement Ambulance expense (within 52 weeks of accident)	$2,500	$3,000	$5,000
Dental services (within 52 weeks of accident)	$400	$500	$1,000
Medical and hospital expense (for illness while policy in force)	None	$1,000	$1,500
Medical expenses from these specified diseases: Poliomyelitis Diphtheria Scarlet Fever Smallpox Tetanus Cerebrospinal Meningitis Typhoid Fever Leukemia Primary Encephalitis	None	$3,500	$5,000
Loss of life (within 100 days of accident)	$2,500	$3,000	$5,000
Loss of: Both hands Both feet Total sight of both eyes One hand and one foot (within 100 days of accident)	$7,500	$7,500	$10,000
Loss of: One hand One foot Sight of one eye (within 100 days of accident)	$2,500	$2,500	$5,000