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College Activities Accident Insurance Request for Quote Form
Requested Effective Date of Coverage
Quote Due Date
MM slash DD slash YYYY
School Information:
Company
Name
Email
Address
City
State
Zip
Website
Affiliation
NCAA
NAIA
NJCAA
OTHER
Division
If applicable, please provide the number of participants by gender.
Archery - Total
Badminton - Total
Band - Total
Baseball - Total
Crew - Total
Cross Country Running - Total
Dance - Total
Drill Team - Total
Diving - Total
Equestrian - Total
Fencing - Total
Field Hockey - Total
Football (Tackle) - Total
Football (Flag/Touch) - Total
Golf - Total
Gymnastics - Total
Handball - Total
Ice Hockey - Total
Lacrosse - Total
Mascots - Total
Martial Arts - Total
Racquetball - Total
Riflery - Total
Rodeo - Total
Rowing - Total
Rugby - Total
Sailing - Total
Skiing (Downhill) - Total
Skiing (Cross Country) - Total
Soccer - Total
Softball - Total
Squash - Total
Swimming - Total
Table Tennis - Total
Tennis - Total
Track & Field (indoor) - Total
Track & Field (outdoor) - Total
Volleyball - Total
Water polo - Total
Weightlifting - Total
Wrestling - Total
Other - Total
Previous Insurance Information:
Current Carrier
Current Deductible
Current Max Medical
Current Benefit Period
Current Dental Limit
Current AD&D
Current AD&D Aggregate Limit
Current Expanded Injury
Current HMO/PPO
Current Pre-Exisiting
Current Heart & Circulatory
Current Guest & Recruit
Current Premium Paid
Current Claims Paid
Current Paid As Of Date
One Year Prior Carrier
One Year Prior Deductible
One Year Prior Max Medical
One Year Prior Benefit Period
One Year Prior Dental Limit
One Year Prior AD&D
One Year Prior AD&D Aggregate Limit
One Year Prior Expanded Injury
One Year Prior HMO/PPO
One Year Prior Pre-Existing
One Year Prior Heart & Circulatory
One Year Prior Guest & Recruit
One Year Prior Premium Paid
One Year Prior Claims Paid
One Year Prior Paid As Of Date
Two Years Prior Carrier
Two Years Prior Deductible
Two Years Prior Max Medical
Two Years Prior Benefit Period
Two Years Prior Dental Limit
Two Years Prior AD&D
Two Years Prior AD&D Aggregate Limit
Two Years Prior Expanded Injury
Two Years Prior HMO/PPO
Two Years Prior Pre-Existing
Two Years Prior Heart & Circulatory
Two Years Prior Guest & Recruit
Two Years Prior Premium Paid
Two Years Prior Claims Paid
Two Years Prior Paid As Of Date
Three Years Prior Benefit Period
Three Years Prior Deductible
Three Years Prior Max Medical
Three Years Prior Carrier
Three Years Prior Dental Limit
Three Years Prior AD&D
Three Years Prior AD&D Aggregate Limit
Three Years Prior Expanded Injury
Three Years Prior HMO/PPO
Three Years Prior Pre-Existing
Three Years Prior Heart & Circulatory
Three Years Prior Guest & Recruit
Three Years Prior Premium Paid
Three Years Prior Claims Paid
Three Years Prior Paid As Of Date
Four Years Prior Benefit Period
Four Years Prior Deductible
Four Years Prior Carrier
Four Years Prior Max Medical
Four Years Prior Dental Limit
Four Years Prior AD&D
Four Years Prior AD&D Aggregate Limit
Four Years Prior Expanded Injury
Four Years Prior HMO/PPO
Four Years Prior Pre-Existing
Four Years Prior Heart & Circulatory
Four Years Prior Guest & Recruit
Four Years Prior Premium Paid
Four Years Prior Claims Paid
Four Years Prior Paid As Of Date
Please provide any information on sports changes (added/removed)
Travel To/From
Yes
No
Accidental Death
Accidental Dismemberment
Accidental Paralysis
Accidental Medical Expense
Deductible
Please provide coverage for: (select all that apply)
Pre-exisiting conditions
HMO/PPO denials
Expanded Medical
Heart & Circulatory
Dental Coverage
Guest & Recruit
Select a choice
Excess
Primary
Maximum Benefit Period
52 weeks
104 weeks
Other Benefits Requested
Aggregate limit per occurrence (standard is 10 times the Accidental Death benefit)
Prior coverage:
Is there a plan currently in force?
Yes
No
If yes, please provide carrier name
Effective date
MM slash DD slash YYYY
Please provide us with a copy of the current effective policy, premium, and lost history for the last three years.
Accepted file types: pdf, doc, docx, Max. file size: 256 MB.
Producer Information:
Name of agency
Contact
Address
City
State
Zip
Phone
Email
Requested commission: 15% is standard
Are you a licensed A&H producer in the applicable risk state(s)?
Yes
No
Are you an appointed producer with Great American Insurance Company?
Yes
No
I here by acknowledge that all answers and statements contained on this form are complete and accurate. I also understand that no coverage will become effective until an application has been approved by the Company.
Please email any attachments to
[email protected]
.
Initial to agree to the above statement.
Date
MM slash DD slash YYYY
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