1st Agency: K-12 Coverage Request for Quote
Blanket student and/or athletic accident coverage
SCHOOL INFORMATION INFORMATION PROVIDED BY
NAME OF SCHOOL DISTRICT * CONTACT NAME *
STREET ADDRESS * PHONE NUMBER *
CITY * EMAIL ADDRESS *
STATE *    
ZIP CODE *  
   
COVERAGE INFORMATION PLAN INFORMATION
CURRENT PLAN Mandatory for all Students and Athletes
MAXIMUM Mandatory for all Athletes Only
DEDUCTIBLE Mandatory for all Students Only (No Sports)
   
CLAIM HISTORY: Please list for the last four school years. SCHOOL INFORMATION
  Premium Paid Claims Paid
2016-2017
2015-2016
2014-2015
2013-2014

 

  Enrollment Number of Schools
High Schools
Middle Schools
Elementary Schools
Total Enrollment (K-12)  
QUOTE REQUEST Please indicate which plan(s) you desire quoted: *
Date Quote Needed: Mandatory for all Students and Athletes

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

Mandatory for all Athletes Only
Mandatory for all Students Only (No Sports)
Other (ie: Deductible, etc.)

 

COVERED PARTICIPANTS


Please check covered participants for High School below.

  MALE FEMALE     MALE FEMALE     MALE FEMALE     MALE FEMALE  
BASEBALL   FOOTBALL (SPRING)   ROWING CREW   TRACK & FIELD (OUTDOOR)  
BASKETBALL   GOLF   SOCCER   VOLLEYBALL  
CHEERLEADERS   GYMNASTICS   SOFTBALL   WRESTLING  
CROSS COUNTRY   ICE HOCKEY   STUDENT MANAGERS / TRAINERS          
FOOTBALL (FALL)   LACROSSE   SWIMMING          
OTHER SPORTS (Please list Male and Female Participants):


Please check covered participants for Middle School below.

  MALE FEMALE     MALE FEMALE     MALE FEMALE     MALE FEMALE  
BASEBALL   FOOTBALL (SPRING)   ROWING CREW   TRACK & FIELD (OUTDOOR)  
BASKETBALL   GOLF   SOCCER   VOLLEYBALL  
CHEERLEADERS   GYMNASTICS   SOFTBALL   WRESTLING  
CROSS COUNTRY   ICE HOCKEY   STUDENT MANAGERS / TRAINERS          
FOOTBALL (FALL)   LACROSSE   SWIMMING          
OTHER SPORTS (Please list Male and Female Participants):