STUDENT HEALTH INSURANCE REQUEST FOR INFORMATION
INSTITUTION INFORMATION:
Name of Institution:
Address:
City:
State:
Zip Code:
RESPONSIBLE SCHOOL OFFICIAL:
Name:
Job Title:
Telephone Number:
TYPE OF PLAN:
Check all applicable. Please send a brochure of your present Student Health Plan.
Mandatory Accident
Mandatory Sickness
Voluntary Accident
Voluntary Sickness
Waiver Accident
Waiver Sickness
Other
Please describe
:
Other
Please describe
:
Current Year Number of Students in College
Men
Women
Current Year Number of Students on Insurance Plan
Men
Women
Current Year Number of Resident Students Total
Men
Women
LOSS EXPERIENCE INFORMATION
Please include current, as well as the last 3 years of information.
If benefits were changed in the past 3 years, please send a copy of the brochure for the appropriate year(s).
YEAR
TOTAL PREMIUMS
PAID CLAIMS
NUMBER OF INSURED CLAIMANTS
PREMIUM RATES
Indicate rates charged for the current and past three years
YEAR:
Student
Student/Spouse
Student/Spouse/Child(ren)
HEALTH SERVICE INFORMATION
DO YOU HAVE AN INFIRMARY?
Yes
No
DO YOU HAVE A DISPENSARY?
Yes
No
NUMBER OF BEDS
WHAT SERVICES ARE PROVIDED FREE OF CHARGE TO STUDENTS?
DATE QUOTE NEEDED:
