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Intercollegiate, Club and Intramural Sports

All States
All Fields with (*) are Required 		 
   
Name of School *
Street Address *
City *
County *
State *
Zip *
   

If Intercollegiate and/or Club Sports are insured separately from the 24 Hour Student Insurance plan, you must provide the following information:

Is the school an NCAA member?* Yes       No             If yes, what division?
  Label- Label Label- Label  Label- Label  Label- Label 
Insurance Co.
Maximum Accident Medical
Maximum Dental
AD&D Limit
Deductible Amount
Deductible Type
Benefit Period
HMO/PPO
Expanded Medical
Pre-existing Condition
Heart & Circulatory
 

Premium & Claims History (Include a current, system-generated report for each policy year)

Year Insurance Co. Gross Premium Paid Total Claims Paid # of Claims Paid
Label-Label
Label-Label
Label-Label
Label-Label
Date of last report

Note: It is also very important that we receive the most information possible. Please submit all claim runs, experience reports etc. These are extremely valuable in developing the most accurate claims projections.
   
Insurance Broker
Contact
Street Address
City
County
State
Zip
Tel # --
Fax # --
Email
Date
 
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