Basic & Catastrophe Coverage All States All Fields with (*) are Required
Street Address *
City *
County *
State *
Zip *
Name of Person Completing this Form *
First Name *
Last Name *
Telephone Number *
E-mail Address*
What is the number of enrolled students in: *
a) Head Start, Nursery or Pre-kindergarten
b) K-8
c) 9-12
d) Adult Education
e) Continuing Education
f) Post-graduate
(The accident insurance policy does not provide Workers Compensation benefits. If your school does not provide Workers Compensation benefits for their Teachers or Administrators and you would like Accident insurance benefits for this exposure, please include the number to be covered here.)
Number of Junior High Schools
Number of Senior High Schools
Number of Junior High Schools that sponsor interscholastic tackle football teams
Number of Senior High Schools that sponsor interscholastic tackle football teams
Estimated Number of Junior High Athletes
Estimated Number of Senior High Athletes
Do any students board at the school? *
What is the current Policy Expiration Date? *
Name of Current Insurance Company *
Name of current insurance plan (eg. AAA, Gold, Plan P, Economy etc.) *
Current plan deductible amount *
Current plan deductible type *
Is the current plan deductible self-insured by the school? *
Does the school have a separate policy that provides Catastrophic Accident benefits? * Note : If "No", proceed to question # 22; if "Yes" then:
b) What is the Accident Medical Expense limit?
c) What is the deductible?
d) What is the Benefit Period?
e) What is the name of the insurance company?
Please complete the following Premium & Claims Paid grid or send us copies of paid claims reports for the past four policy years beginning with the current year. (The reports should reflect payment activity for each year that is no later than two months from today's date.)
If the answer to question #7 above is not an insurance broker or agent, please let us have your broker or agent's name and telephone number if you would like us to work with him or her for the purpose of developing a quote.
Broker First Name
Broker Last Name
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