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