SCHOOL STUDENT/ATHLETIC ACCIDENT INSURANCE

QUESTIONNAIRE

 

In order to present you with a proper proposal for your student athletic accident insurance for the coming year, we will need some information. Please fill out this form, return it to me, and we will have a firm fixed price proposal on this fine plan to you in a few days.

Name of School (District)___________________________________________________________________

Address_________________________________________________________________________________

City_____________________________State_____________Zip____________Phone___________________

Administrator responsible for Student Ins.______________________________________________________

Grades included in School (District)____________ Number of High Schools (District)___________________

Do you insure all Students? Yes(  ) NO(  ) Number of Students_______________________

K-6 (8)___________________________7 (9) -12___________________________________

Current Carrier (Administrator)________________________________________________________________
Premium & Losses (for the last 3 years) Policy Year Premium Losses Paid
     
     
     

Please fill in below, the number of participants during the current year, in the high school interscholastic sports
sponsored by your school (district). If you have tackle football on a level below the high school freshman level,
include that in the "other" column.

 NOTE: If you insure ALL students, you need not fill out the form below.
 
SPORT MALE FEMALE

SPORT           

MALE FEMALE
BASEBALL     RIFLE    
BASKETBALL     SKIING    
BOWLING     SOCCER    
CROSS COUNTRY     SOFTBALL    
FENCING     SWIMMING    
FIELD HOCKEY     TENNIS    
FOOTBALL     TRACK    
GYMNASTICS     VOLLEYBALL    
GOLF     WEIGHTLIFTING    
ICE HOCKEY     WRESTLING    
LACROSSE     OTHER    

We will be most happy to coordinate the program through your local agent or broker. If you wish to work with the
broker, please provide the information below.
 
Name of agent or Broker_________________________________________________________________________
contact_______________________________________________________________________________________
Address_______________________________________City__________________State_________Zip__________