Athletic Accident Medical Insurance Quotation Request Form

Main Information:    
Name of Institution:*
       
Address:* City:* State:* Zip:*
       
Name:* Title: Phone:* Fax:
       
Email:* Affiliation:
NCAA NAIA NJCAA NCCAA Other
 

Part A - covered participants:
Sports Men Women
Band
Baseball
Basketball
Bowling
Cheerleading
Cross Country
Dance/Drill Team
Equestrian
Football, Tackle (Fall)
Football, Tackle (Spring)
Football, Touch/Flag
Golf
Gymnastics
Hockey, Field
Hockey, Ice
Lacrosse
Rodeo
 
Sports Men Women
Rugby
Soccer
Softball
Student Coaches
Student Managers
Student Trainers
Swimming / Diving
Tennis
Track & Field (Indoor)
Track & Field (Outdoor)
Volleyball
Water Polo
Wrestling
Other (List Below)
   
Total
 

Part B - Risk Management Information:
Certified athletic trainer(s) on staff?
yes no
Team Physician:
on staff on retainer other
Physician's Specialty:
Is physician board certified?
yes no
Does the athletic department or coaching staff routinely:  
Obtain information about athlete's other insurance coverage?
yes no
Require pre-participation physical examination?
yes no
For which sports?
Type of institution?
public private
Type of surface where activities take place?
artifical grass
What other activities take place on this surface?
Does your institution have a medical school which provides care at no cost to athletes?
yes no
What percentage of your student athletes have primary medical coverage?
Does your institution have formal written agreements in place with preferred medical providers?
yes no
Is primary insurance required as a condition of participation?
yes no
 

Part C - Previous insurance information:
Benefits 3 Years
Previous
2 Years
Previous
1 Year
Previous
Current
Year
Medical Maximum Limit
Excess or Primary
Deductible Reducing or Corridor
Benefit Period (weeks)
Accidental Death & Dismemberment Benefit
Coverage for overuse injuries/conditions (Y/N)
Coverage for HMO/PPO denials (Y/N)
Coverage for re-injury/re-aggravation (Y/N)
Coverage for Heart & Circulatory (Y/N)
Insurance Carrier
Premium        
Basic
Catastrophic
CLAIMS HISTORY*        
Number of Claims Paid
Total Amount of Claims Paid
As of (mm/dd/yyyy)
         
*PLEASE ATTACH CARRIER LOSS REPORTS FOR ALL YEARS DATED NO EARLIER THAN 3/1 of the current year.
 

Part D - Options:
Deductible:
$0 $250 $500 $1500 $2,500
$5,000 Aggregate Other
Accidental Death & Dismemberment Benefit:
$10,000 $25,000 $50,000 $100,000    
                   
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 (AD&D):
yes no
 
Would you like to see an additional quote for:
Expanded cheerleading coverage?
yes no
Deductible administration plan?
yes no
Deductible aggregate plan?
yes no
Catastrophic insurance?
yes no