Collegiate Sports Program Insurance

Collegiate Sports Application —
Intercollegiate, Club, and Intramural Sports

Complete to obtain a quotation for basic athletic insurance for your intercollegiate, club or intramural sport programs from first dollar up to $75,000 medical limit.

Required Field

NAME OF SCHOOL:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
EMAIL:
CONTACT NAME:
TITLE:
NCAA, NAIA OR NJCAA:
DIVISION:
DATE PROPOSAL NEEDED:

NUMBER OF PARTICIPANTS
SPORTS	MEN	WOMEN	TOTAL
Baseball
Basketball
Cheerleading
Cross Country
Fencing
Football (Fall)
Football (Spring)
Field Hockey
Golf
Ice Hockey
Lacrosse
Soccer
Softball
Student Managers
Student Trainers
Swim/Dive
Tennis
Track & Field
Volleyball
Wrestling
Other





Subtotals

Total Participants

POLICY YEAR	2003-2004	2004-2005	2005-2006	2006-2007	2007-2008

CARRIER
DEDUCTIBLE
AGGREGATE DED.
MEDICAL MAX
BENEFIT PERIOD
AD&D
PREMIUM PAID
CLAIMS PAID
PAID AS OF DATE
# OF CLAIMS PAID