STUDENT ACCIDENT AND SICKNESS QUESTIONNAIRE

 

NAME OF COLLEGE OR UNIVERSITY__________________________________________

ADDRESS___________________________________________________________________

CITY          ______________________________________________STATE‑ ZIP______________

STUDENT CENSUS________________________________________________

FULL TIME__________________WN_________WOMEN______TOTAL____

PART TIME__________________WN_________WOMEN______TOTAL____

 

PREMIUM AND LOSS EXPERIENCE

YEAR

TOTAL PREMIUM

PAID LOSSES

NO. INSURED

CURRENT

 

 

 

3 prior years

 

 

 

 

PREMIUM RATES

YEAR

STUDENT

STUD. AND

SPOUSE

STUD./SPOUSE

CHILDREN

CURRENT

 

 

 

3 prior years

 

 

 

 

PLEASE ENCLOSE A BROCHURE OF YOUR PLAN FOR THE PAST 3 YEARS

WHAT IS YOUR CURRENT METHOD OF ENROLLMENT??

COMPULSORY __ WAIVER[  ]   VOLUNTARY [  ]

DO YOU WANT ANY INTERCOLLEGIATE SPORTS COVERAGE?  YES[  ]  No[  ]

PERSON RESPONSIBLE FOR STUDENT A & S INSURANCE:_________________________

NAME_________________________________________________________________________

TITLE__________________________PHONE_________________________________________

 

BOB MC CLOSKEY INSURANCE

76 MAIN ST., PO BOX 511

 MATAWAN, NJ 07747 

1‑800‑445‑3126