1st Agency: College Sports Information Request
For College Administrators
INSTITUTION INFORMATION INFORMATION PROVIDED BY
NAME OF INSTITUTION * YOUR NAME *
STREET ADDRESS * JOB TITLE *
CITY * PHONE NUMBER *
STATE * EMAIL ADDRESS *
ZIP CODE *  
   
PLEASE INPUT NUMBER OF PARTICIPANTS FOR EACH SPORT:
  FEMALE MALE     FEMALE MALE     FEMALE MALE     FEMALE MALE  
BASEBALL   EQUESTRIAN   LACROSSE   STUDENT MANAGERS / TRAINERS  
BASKETBALL   FENCING   RIFLERY   SWIMMING  
BOWLING   FIELD HOCKEY   RODEO   TENNIS  
CHEERLEADERS   FOOTBALL (FALL)   ROWING CREW   TRACK & FIELD (INDOOR)  
COMPETITIVE
CHEER
  FOOTBALL (SPRING)   SAILING   TRACK & FIELD (OUTDOOR)  
CROSS COUNTRY   GOLF   SKIING   VOLLEYBALL  
DANCE   GYMNASTICS   SOCCER   WATER POLO  
DIVING   ICE HOCKEY   SOFTBALL   WRESTLING  
OTHER SPORTS (Please list Male and Female Participants):
AFFILIATION: NCAA NAIA NJCAA Other
PREVIOUS INSURANCE INFORMATION - CURRENT YEAR:


Please list information for 2016-2017 below.

Maximum Medical Excess or Primary Deductible Benefit Period Accidental Death Benefit

Coverage for Overuse Injuries / Conditions? Yes No
Coverage for Heart / Circulatory Conditions? Yes No
Coverage for HMO / PPO Denials? Yes No
Coverage for Pre-Existing Conditions? Yes No

Premium : Basic Premium: Catastrophic Number of Claims Paid Amount of Claims Paid Through (Date)

 

PREVIOUS INSURANCE INFORMATION - PAST THREE YEARS:


Please list information for 2015-2016 below.

Maximum Medical Excess or Primary Deductible Benefit Period Accidental Death Benefit

Coverage for Overuse Injuries / Conditions? Yes No
Coverage for Heart / Circulatory Conditions? Yes No
Coverage for HMO / PPO Denials? Yes No
Coverage for Pre-Existing Conditions? Yes No

Premium : Basic Premium: Catastrophic Number of Claims Paid Amount of Claims Paid Through (Date)


Please list information for 2014-2015 below.

Maximum Medical Excess or Primary Deductible Benefit Period Accidental Death Benefit

Coverage for Overuse Injuries / Conditions? Yes No
Coverage for Heart / Circulatory Conditions? Yes No
Coverage for HMO / PPO Denials? Yes No
Coverage for Pre-Existing Conditions? Yes No

Premium : Basic Premium: Catastrophic Number of Claims Paid Amount of Claims Paid Through (Date)

 


Please list information for 2013-2014 below.

Maximum Medical Excess or Primary Deductible Benefit Period Accidental Death Benefit

Coverage for Overuse Injuries / Conditions? Yes No
Coverage for Heart / Circulatory Conditions? Yes No
Coverage for HMO / PPO Denials? Yes No
Coverage for Pre-Existing Conditions? Yes No

Premium : Basic Premium: Catastrophic Number of Claims Paid Amount of Claims Paid Through (Date)

 

OPTIONS TO BE QUOTED:

Deductible *

Date Quote Needed:
If Other, please list: Accidental Death Benefit

Coverage for Overuse Injuries / Conditions? * Yes No
Coverage for Heart / Circulatory Conditions?* Yes No
Coverage for HMO / PPO Denials? * Yes No
Coverage for Pre-Existing Conditions? * Yes No
Benefit Period? * 1 Year 2 Years
 
Coverage for Guests / Recruits? Yes No
Is Catastrophic Coverage desired? Yes No

 

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