Name of Institution:*            NCAA I NCAA II NCAA III NAIA NJCAA Other
Address:*
City:*		State:*	Select a StateAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKOROTPARISCSDTNTXUTVAVTWAWIWVWY	Zip:*
Contact Name:*		Title:
Daytime Phone:*		Fax:
Contact Email:*

Part A - COVERED INTERCOLEGIATE PARTICIPANTS:

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SPORT	MEN	WOMEN		SPORT	MEN	WOMEN
BAND				SKIING
BASEBALL				SOCCER
BASKETBALL				SOFTBALL
CHEERLEADING				STUDENT COACHES
CROSS COUNTRY				STUDENT MANAGERS
DRILL TEAM				STUDENT TRAINERS
EQUESTRIAN				SWIMMING/DIVING
FIELD HOCKEY				TENNIS
FOOTBALL (FALL)				TRACK & FIELD
FOOTBALL (SPRING)				VOLLEYBALL
GOLF				WATER POLO
GYMNASTICS				WRESTLING
ICE HOCKEY				OTHER (LISTED BELOW)
LACROSSE
RIFLERY
RODEO
ROWING/CREW
RUGBY

Part B - PREVIOUS INSURANCE INFORMATION:

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BENEFITS	3 YEARS PREVIOUS	2 YEARS PREVIOUS	1 YEARS PREVIOUS	CURRENT YEAR
Medical Maximum Limit
Excess or Primary	ExcessPrimary	ExcessPrimary	ExcessPrimary	ExcessPrimary
Deductible   Reducing Corridor
Benefit Period (# of Weeks)	52104156	52104156	52104156	52104156
Accidental Death Benefit
Coverage for overuse injuries/conditions	YesNo	YesNo	YesNo	YesNo
Coverage for HMO/PPO denials	YesNo	YesNo	YesNo	YesNo
Coverage for re-injury/re-aggravation	YesNo	YesNo	YesNo	YesNo
Coverage for Heart & Circulatory	YesNo	YesNo	YesNo	YesNo
Insurance Carrier Name
PREMIUM
Basic
CLAIMS HISTORY **
Number of Claims Paid
Total Amount of Claims Paid
As of (mm/dd/yyyy)

** 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:

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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

Part D - OPTIONS:

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Deductible: $0 $250 $500 $1000 $1500 $2500 $5000  Other:  Other:
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: $10000 $25000 $5000 $100000  Other:
Would you like to also see a quote for the following plans?	Self-Funding/Aggregrate Deductible Expanded Cheerleading Coverage

Part E - COMMENTS:

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Please add any comments: (255 char. max)

 
 

QUOTE NEEDED BY: (mm/dd/yyyy)*
DESIRED EFFECTIVE DATE: (mm/dd/yyyy)*

 

Enter the letters and numbers that are below

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