Service Center
Home
Products
About
News
Contact Us
Home
Products
About
News
Contact Us
Service Center
Risk Strategies - Academic Health Plans
Basic Accident Medical Insurance Request for Quotation
Basic Accident Medical Insurance Request for Quotation
Name of Institution
*
NCAA I
NCAA II
NCAA III
NAIA
NJCAA
NCCAA
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Name
*
Title
Daytime Phone
*
Fax
Contact Email
*
Agent/Broker
Part A - COVERED INTERCOLLEGIATE PARTICIPANTS:
Sport
MEN
WOMEN
Sport
MEN
WOMEN
BAND
Men
Women
RIFLERY
Women
Men
BASEBALL
Men
Women
RODEO
Men
Women
BASKETBALL
Men
Women
ROWING/CREW
Men
Women
CHEERLEADING
Men
Women
RUGBY
Men
Women
CROSS COUNTRY
Men
Women
SKIING
Men
Women
DANCE TEAM
Men
Women
SOCCER
Men
Women
DRILL TEAM
Men
Women
SOFTBALL
Men
Women
EQUESTRIAN
Men
Women
STUDENT COACHES
Men
Women
FIELD HOCKEY
Men
Women
STUDENT MANAGERS
Men
Women
FOOTBALL (FALL)
Men
Women
STUDENT TRAINERS
Men
Women
FOOTBALL (SPRING)
Men
Women
SWIMMING/DIVING
Men
Women
GOLF
Men
Women
TENNIS
Men
Women
GYMNASTICS
Men
Women
TRACK & FIELD
Men
Women
ICE HOCKEY
Men
Women
VOLLEYBALL
Men
Women
LACROSSE
Men
Women
WATER POLO
Men
Women
MASCOTS
Men
Women
WRESTLING
Men
Women
POM SQUADS
Men
Women
Other Sports
Sport Name
Men
Women
Part B - PREVIOUS INSURANCE INFORMATION:
(A minimum of the current year plus 3 prior years history required for underwriting)
Benefits
2016/2017
2017/2018
2018/2019
2019/2020
Medical Maximum Limit
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
Excess or Primary
Excess|Primary
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
Deductible
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
Benefit Period (# of Weeks)
104|52|156
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
Accidental Death Benefit
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
Coverage for overuse injuries/conditions
YES|NO
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
Coverage for HMO/PPO denials
YES|NO
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
Coverage for re-injury/re-aggravation
YES|NO
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
Coverage for Heart & Circulatory
YES|NO
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
Insurance Carrier Name
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
PREMIUM
Basic
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
CLAIMS HISTORY **
Total Amount of Claims Paid
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
As of (mm/dd/yyyy)
3 YEARS PREVIOUS
2 YEARS PREVIOUS
1 YEAR PREVIOUS
CURRENT YEAR
** YOU WILL BE REQUIRED TO SUBMIT CARRIER LOSS REPORTS FOR ALL YEARS DATED NO EARLIER THAN 3/1 OF THE CURRENT YEAR.
Part C - QUESTIONS:
1. What percentage of your student-athletes have primary medical coverage?
2. Do you have a Certified Athletic Trainer on staff?
YES
NO
3. Does the Athletic Department routinely obtain information about the student-athletes' other insurance coverage?
YES
NO
4. Have any sports been added or remove in the last 4 years?
YES
NO
Which sport(s) were added or deleted during which policy year?
Part D - OPTIONS:
Deductible
Hold the shift key to select multiple amounts.
$0
$250
$500
$1.000
$2,500
Coverage for overuse injuries/conditions:
YES
NO
Coverage for HMO/PPO denials:
YES
NO
Coverage for re-injury/re-aggravation:
YES
NO
Coverage for heart & circulatory:
YES
NO
Accidental Death & Dismemberment Benefit:
$10,000
$15,000
$25,000
$50,000
$100,000
Would you like to also see a quote for the following plans?
Self-Funding/Aggregrate Deductible
Expanded Cheerleading Coverage
Part E - COMMENTS:
Please provide detailed claims history for the past 3 years plus current policy.
Drop files here or
Select files
Max. file size: 40 MB.
Please add any comments:
QUOTE NEEDED BY: (mm/dd/yyyy)
MM slash DD slash YYYY
DESIRED EFFECTIVE DATE: (mm/dd/yyyy)
MM slash DD slash YYYY
CAPTCHA
Recent Posts
First Annual Student Health Benchmarking Survey
Surveying college students about what they want
Protecting Against Rising Athletic Insurance Premiums
Athletic Insurance Consultant/Broker Services Request for Proposal
Archives
June 2021
March 2021
February 2021
Categories
Uncategorized
Meta
Log in
Entries feed
Comments feed
WordPress.org
