COLLEGE ATHLETIC ACCIDENT INSURANCE QUESTIONNAIRE

In order to present you with a proper proposal for your 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 College or University:________________________________________________________________

Address:____________________________________________________________________________________

City:_____________________State:_________Zip:________Phone:___________________________________

Administrator responsible for Sports Accident Ins.:_______________________________________________

Current Carrier (Administrator) _________________________________________________________________

Would you consider other deductible options other than those above?  YES____   NO_____

 Please fill in below the number of participants during the current year, in the intercollegiate sports program sponsored by your college.

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.
 

We can also provide coverage for intramural and club sport activities, and accident and liability insurance for any CAMPS sponsored by the college or any of the athletic department personnel.

BOB MC CLOSKEY INSURANCE
76 MAIN ST., PO BOX 511
MATAWAN, NJ 07747
1‑800‑445‑3126