UC Statewide Campers Audit Form






Audit Premium Calculator

Note: Minimum Premium is $25.00.

Youth Athletic
Youth Non-Athletic
Adult


Yes(add $0.03)
No

$

Billing Information






 




 

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 Michelle Dalsing at mdalsing@cpinsco.com if you have any questions about this form.

CONTACT INFO

Heather Woodruff
Client Executive 877.428.5578
Email