Student Insurance, Athletic Accident Coverage, Special Risk Insurance, Summer Camps, Little Leagues

5071 WEST H AVENUE | KALAMAZOO, MI 49009 | 269.381.6630

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1st Agency: College Sports Information Request

FOR COLLEGE ADMINISTRATORS

INSTITUTION INFORMATION

Name of Institution *

Street Address *

City *

State *

Zip Code *

INFORMATION PROVIDED BY

Your Name *

Job Title *

Phone Number *

Email Address *

PLEASE INPUT NUMBER OF PARTICIPANTS FOR EACH SPORT:

FEMALE

MALE

FEMALE

MALE

FEMALE

MALE

FEMALE

MALE

Acrobatics Tumbling

Baseball

Basketball

Bowling

Cheerleaders

Competitive Cheer

Cross Country

Cycling

Dance

Diving

E-Sports

Equestrian

Fencing

Football(Fall)

Football (Spring)

Field Hockey

Golf

Gymnastics

Ice Hockey

Lacrosse

Riflery

Rodeo

Rowing Crew

Rugby

Sailing

Skiing

Soccer

Softball

Student Managers

Student Trainers

Swimming

Tennis

Track & Field(Indoor)

Track & Field(Outdoor)

Volleyball

Water Polo

Wrestling

OTHER SPORTS (Please list Male and Female Participants) :

AFFILIATION:

NCAA

NAIA

NJCAA

Other

Other Affiliation

PREVIOUS INSURANCE INFORMATION - CURRENT YEAR:

Please list information for 2022-2023 below.

Maximum Medical

Excess or Primary

Deductible

Benefit Period

Accidental Death Benefit

Premium : Basic

Premium: Catastrophic

Number of Claims Paid

Amount of Claims Paid

Through (Date)

PREVIOUS INSURANCE INFORMATION - PAST THREE YEARS:

Please list information for 2021-2022 below.

Maximum Medical

Excess or Primary

Deductible

Benefit Period

Accidental Death Benefit

Premium : Basic

Premium: Catastrophic

Number of Claims Paid

Amount of Claims Paid

Through (Date)

Please list information for 2020-2021 below.

Maximum Medical

Excess or Primary

Deductible

Benefit Period

Accidental Death Benefit

Premium : Basic

Premium: Catastrophic

Number of Claims Paid

Amount of Claims Paid

Through (Date)

Please list information for 2019-2020 below.

Maximum Medical

Excess or Primary

Deductible

Benefit Period

Accidental Death Benefit

Premium : Basic

Premium: Catastrophic

Number of Claims Paid

Amount of Claims Paid

Through (Date)

OPTIONS TO BE QUOTED:

If Other, please list:

Date Quote Needed:

Accidental Death Benefit

Please enter any other pertinent information you would like to add here:

CONTACT US

Address

5071 WEST H AVENUE | KALAMAZOO, MI 49009

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269.381.6630

Mail

1stAgency@1stAgency.com

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