UC Statewide Campers Audit Form

CONTACT INFO

Silvana Brezac
Barney & Barney's Bay Area Office:
p - (510) 466-6036

UC Statewide Campers Audit Form

University of California at:
Group Activity:
Description of Activity:
Beginning Date:
Ending Date:

Audit Premium Calculator

Note: Minimum Premium is $25.00.

Select the type of activity Youth Athletic
Youth Non-Athletic
Adult
Enter # of Camp Days
(or weeks for Adult Camps)
Enter # of Campers
Calculate Audit Premium
Audit Premium Due $

Optional Sickness Benefit Calculator

Enter # of Camp Days
Enter # of Campers
Calculate Sickness Benefit
Sickness Benefit Due $

Billing Information

Name:
Company Name:
Address:
Phone:
e-mail:

Authorized By:
Title:
Email Address:
Date: 09/05/2010

This form serves as your invoice, please print this page using your browser's Print button and mail a copy of this form with a check payable to Consolidated Program Insurance Services, 77 Mark drive, Suite 26, San Rafael, CA 94903 in order to bind coverage.

Please contact Silvana Brezac at 510-466-6036 if you have any questions about this form.

Barney & Barney LLC

CONTACT INFO