First Agency, Inc. of Kalamazoo, Michigan - The Leader in Student and Athletic

K - 12 COVERAGE INFORMATION REQUEST FORM

Name of School District:

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Contact Name:

Job Title:

Present Insurance Company:

CURRENT COVERAGE:

	Mandatory for all Students and Athletes
	Mandatory for all Athletes Only
	Mandatory for all Students Only (no sports)
	Voluntary for all Students and/or Athletes
	Catastrophic

Deductible:
Maximum:

PLEASE PROVIDE THE FOLLOWING INFORMATION:
Please include current, as well as the last 3 years of information.

K-12 ENROLLMENT	# OF HIGH SCHOOLS:	# OF JUNIOR HIGHS:

PLEASE INDICATE WHICH PLAN(S) YOU DESIRE QUOTED:

	Mandatory for all Students and Athletes
	Mandatory for all Athletes Only
	Mandatory for all Students Only (no sports)
	Voluntary for all Students and/or Athletes
	Catastrophic
	Other (i.e.: deductible, etc.)

DATE QUOTE NEEDED: