5071 WEST H AVENUE | KALAMAZOO, MI 49009 | 269.381.6630
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1st Agency: K-12 Coverage Request for Quote

BLANKET STUDENT AND/OR ATHLETIC ACCIDENT COVERAGE

SCHOOL INFORMATION

INFORMATION PROVIDED BY


COVERAGE INFORMATION

PLAN INFORMATION


CLAIM HISTORY: Please list for the last four school years.

SCHOOL INFORMATION


2021-2022

2020-2021

2019-2020

2018-2019

Premium Paid

Claims Paid

High Schools Text

High Schools

Middle Schools

Elementary Schools

Total Enrollment (K-12)

Enrollment

Number of Schools


QUOTE REQUEST

Please indicate which plan(s) you desire quoted


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



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