Request a quote Choose from athleticcareTM or secondary insurance options.athleticcare℠ MEDICAL INSURANCE QUOTATION REQUEST FORM Main Information Name of Institution (required) Address (required) City (required) State (required) Zip (required) Name (required) Title (required) Phone (required) Fax Email (required) Affiliation NCAANAIANJCAANCCAAOtherDo you currently offer a school sponsored health plan? YesNo Estimated number of athletes needing coverage: Secondary Athletic Accidental Medical Insurance Quotation Request Form Main Information Name of Institution (required) Address (required) City (required) State (required) Zip (required) Name (required) Title (required) Phone (required) Fax Email (required) Affiliation NCAANAIANJCAANCCAAOtherNumber of Covered Participants 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 Rugby Soccer Softball Student Coaches Student Managers Student Trainers Swimming/Diving Tennis Track & Field (Indoor) Track & Field (Outdoor) Volleyball Water Polo Wresting Other Previous Insurance InformationBenefitsMedical Maximum Limit Excess or Primary Deductible (Reducing) Deductible (Corridor) Benefit Period (weeks) Accidental Death & Dismemberment Benefit Coverage of overuse injuries/conditions (Y/N) Coverage of HMO/PPO denials (Y/N) Coverage of re-injury/re-aggravation (Y/N) Coverage of Heart & Circulatory (Y/N) PremiumBasic Catastrophic Claims HistoryNumber of Claims Paid Total Amount of Claims Paid
