Skate-Pak Application
Name:
Address:
Home Phone:
Bus. Phone:
Amount of Insurance Requested:
$5000
$10 000
Deductible Requested:
$50
$100
Premium Rates:
$5000 @ $50 Deductible = $50
$5000 @ $100 Deductible = $35
$10 000 @ $50 Deductible = $75
$10 000 @ $100 Deductible = $60
Premium "Attached":
Card Type:
Visa
MasterCard
Card No.:
Expiry Date:
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