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Get Accident Medical Applications and ACH Forms

GrouProtector provides group accident medical coverage for a wide variety of groups and group activities, ranging from sports, community events, volunteerism, schools, youth activities and so much more. Make sure you and your participants are protected if an accidental injury or death occurs while your group is participating in their group activities.

If you’re ready to apply, get a quote online or print and complete an application for GrouProtectorSM group accident medical insurance. 

Submitting an application

Mail, email or fax your application back to us at the fax number, email address or mailing address provided on the application. Be sure to include a check for first premium payment. To pay by credit card, call 1-800-525-8669. To set up a draft authorization from a checking or savings account, include a Nationwide ACH form.

Specialized Groups Applications

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All Other Applications

Get accident medical ACH forms

Using an ACH (Automated Clearing House) form is a convenient way to pay initial premiums, policy endorsements and even routine bills.

To make a single payment from a checking or savings account, complete the appropriate ACH form and submit it along with your new application, billing statement or policy endorsement. Don’t forget to include your account and routing numbers.  

Nationwide policies

To issue premium payment for a Nationwide policy instead of mailing a check or money order, please use the Nationwide ACH form.

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