COLLEGE SPORTS INFORMATION REQUEST FORM
INSTITUTION INFORMATION:
Name of Institution:  
Address:  
City:  
State:  
Zip Code:  
Telephone Number:  
Fax Number:  
INFORMATION PROVIDED BY:
Name:  
Job Title:  
PLEASE INPUT NUMBER OF PARTICIPANTS FOR EACH SPORT:
SPORTS
MALE
+
FEMALE
=
TOTAL
Baseball
+
=
Basketball
+
=
Cheerleaders
+
=
Cross-Country
+
=
Equestrian
+
=
Fencing
+
=
Field Hockey
+
=
Football (Fall)
+
=
Football (Spring)
+
=
Golf
+
=
Gymnastics
+
=
Ice Hockey
+
=
Lacrosse
+
=
Riflery
+
=
Rodeo
+
=
Rowing Crew
+
=
Sailing
+
=
Skiing
+
=
Soccer
+
=
Softball
+
=
Student Managers / Trainers
+
=
Swimming / Diving
+
=
Tennis
+
=
Track and Field (Outdoor)
+
=
Track and Field (Indoor)
+
=
Volleyball
+
=
Water Polo
+
=
Wrestling
+
=
Others:
+
=
+
=
+
=
TOTAL:
+
=
 
AFFILIATION:
NCAA
NJCAA
NAIA
Other:
PREVIOUS INSURANCE INFORMATION:
YEAR:
(CURRENT YEAR AND PAST THREE)
CURRENT
BENEFITS:
Maximum Medical
Excess or Primary
Deductible
Benefit Period
Accidental Death Benefit
Coverage for Overuse Injuries/Conditions
Yes
Yes
Yes
Yes
No
No
No
No
Coverage for HMO/PPO Denials
Yes
Yes
Yes
Yes
No
No
No
No
Coverage for Heart/Circulatory Conditions
Yes
Yes
Yes
Yes
No
No
No
No
Coverage for Pre-Existing Conditions
Yes
Yes
Yes
Yes
No
No
No
No
PREMIUM:
.
.
.
.
Basic
Catastrophic (if purchased)
CLAIMS PAID:
.
.
.
.
Number of Claims Paid
Dollar Amount of Claims Paid
Through (Date)

(Month/Yr)

(Month/Yr)

(Month/Yr)

(Month/Yr)
 
OPTIONS TO BE QUOTED:
DEDUCTIBLE:
$0
$250
$500
$1000
Other:
COVERAGE FOR PRE-EXISTING CONDITIONS:
Yes
No
COVERAGE FOR HEART / CIRCULATORY CONDITIONS:
Yes
No
COVERAGE FOR OVERUSE INJURIES / CONDITIONS:
Yes
No
COVERAGE FOR HMO/PPO DENIALS:
Yes
No
ACCIDENTAL DEATH BENEFIT:
$
BENEFIT PERIOD:
1 Year
2 Years
IS CATASTOPHIC COVERAGE DESIRED?:
Yes
No
DATE QUOTE NEEDED:
PLEASE ENTER ANY OTHER PERTINENT INFORMATION YOU WOULD LIKE TO ADD HERE:
  
   

 
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