AMA RAMP Insurance Program Enrollment

An asterisk (*) indicates a required field.

This field is for validation purposes and should be left unchanged.
Plan 1: $15,000 - Accidental Death & Dismemberment Principal Sum $5,000 - Excess Accident Medical Expense Benefit $2,500 - Medical Expense Deductible
Plan 2: $20,000 - Accidental Death & Dismemberment Principal Sum $10,000 - Excess Accident Medical Expense Benefit $2,500 - Medical Expense Deductible
Plan 3: $25,000 - Accidental Death & Dismemberment Principal Sum $20,000 - Excess Accident Medical Expense Benefit $2,500 - Medical Expense Deductible
Annual Accident Insurance Plan Cost & Benefit Amounts*

Rider Accident Medical Plan

Accident Insurance Offered and Administered by Jones Birdsong LLP.

Please click on the link below to see the detailed information of the AMA RAMP Insurance Program.

>> AMA RAMP Program Information <<

Eligibility

All members of the AMA are eligible for coverage. Benefits are paid when a member has elected coverage and paid the required premium and then suffers a covered loss while taking part as a registered rider in an AMA amateur or road sanctioned event.

Member Information

Name*
Gender
Date of Birth
Address

Beneficiary Designation

Beneficiary Name
If you do not select a beneficiary, your accidental death benefits will be paid as shown in your Certificate of Insurance.

Terms and Signature

I hereby enroll in the Rider Accident Medical Plan underwritten by Federal Insurance Company a member insurer of the Chubb Group of Companies. I understand that my insurance coverage will be effective on the first day following the receipt of my enrollment form and initial premium. I have read the product brochure Description of Coverage and understand the terms, conditions, limitations and exclusions of the accident insurance program. Coverage is only in effect while I am participating in an event sanctioned by the AMA and the coverage is in force.