Name of School, College or University *

Name of Person Completing this Form *

First Name *

Last Name *

E-mail Address *

Number of Enrolled Students *

          a) Full-time Undergraduate

          b) Part-time Undergraduate

          c) Graduate

          d) Law

Desired Effective Date of Coverage *

Name of Current Third Party Administrator

In order to develop a competitive quotation, the following Underwriting Information should also be sent to us by e-mail, fax or mail:

1. The Premium Paid for the past four years beginning with the current year.
2. Paid Claims Reports for the past four policy years beginning with the current year. The report dates for each year should reflect activity no older than 30 days from the date of submission. There should be one report for accident claims and one report for sickness claims for each year.
3. The Rates Charged for each student and dependent category for the past four years beginning with the current year.
4. The Number of Enrollees for each student and dependent category for the past four years beginning with the current year.
5. A List of the 5 Providers most often used by the students.
6. Copies of the Plan Brochures for the past four policy years beginning with the current year.

For larger schools, colleges or universities, the insurance company may require more detailed paid claims information including: Large Claim, Benefit Code, Prescription Drug Utilization and Payment Trend/Lag reports.