Please Print, Complete
Then Fax This Three-page Form
Request a quote by e-mail
Fax us at 206.292.6692
Call us at 800.AHA.1778
If you are an insurance agency,
please include a fax cover sheet.
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Amateur Sports Insurance Quotation Request Form
Please give us the following details, so we can return a quote.
About You
Requester________________________________________________________
Street Address________________________________________________________
City________________________________State/Zip_________________________
Phone ( )_____________________
About The Coverage You Want
Please note these guidelines:
- Up to $1,000,000, accident medical expense maximum (subject to exclusions and limitations)
- $10,000, accidental dismemberment benefit
- Up to $10,000, accidental death benefit
For the policy you want, please check one option in each column, or write in amounts.
| Coverage |
Medical
Benefit Maximum |
Benefit Period (weeks) |
Deductable |
Accidental
Death Benefit |
| ___ Primary excess over $________ |
___ $250,000 |
___ 52 |
___ None |
___ $5,000 |
| ___ Full excess |
___ $500,000 |
___ 104 |
___ $25 |
___ $10,000 |
| ___ Primary excess |
___ $1,000,000 |
___ 156 |
___ $50 |
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___ Other $_________ |
___ Other $_________ |
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Please note these guidelines. We require no name list, nor do we require a tryout charge. The number of players is subject to audit. Finally, team prices and league discounts are available for baseball, basketball, football and softball.
In this table, please complete the details, using these codes for the age groups:
- A for age 12 and younger
- B for age 13 to 15
- C for age 16 to 18
- D for age 19 and older
| Name of Sport |
Age Group |
Number
of Teams |
Number
of Players |
Effective
Date |
Termination
Date |
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Thank you!
If you prefer, you can mail your quote request to us:
American Health Administrators
PO Box 4586
Seattle WA 98194
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