|
CATASTROPHIC INSURANCE COVERAGE QUESTIONNAIRE In order to present you with a proposal for your Catastrophic 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)_____________________________________________________________ Adress_____________________________________________________________________________ City___________________State__________Zip_______________Phone_______________________ Administrator responsible for Ins._________________________________________________ Grades included in School (District)_________________Number of High Schools (District)________ Do you insure all Students with Catastrophic coverage? Yes____ NO____ Number of Students____________________________ Medical Limit Required ( )$1,000,000 ( )$5,000,000 ( )$10,000,000 Catastrophic Cash Required ( )NONE ( ) $600,000 ( )$1,200, Deductible Required ( ) $10,000 ( )$25,000 ( )$100,000 ( )$1,000,000 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.
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__________________________________________PHONE____________________________ ADDRESS___________________________________CITY_________
BOB MC CLOSKEY INSURANCE |