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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College Student Accident Medical Expense and Health Insurance Quotation Request Form
Please give us the following details, so we can return a quote.
Name of College ________________________________________________________
Street Address ________________________________________________________
City ________________________________State/Zip_________________________
Phone ( )_____________________
School Official
(your name) _________________________________
Your e-mail address ___________________@________________
Note To complete the form, please check the line in front of the option you want, or fill in the details requested.
Full-time Enrollment
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Domestic |
Foreign (J1-F1 Visas) |
| Male |
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| Female |
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| ___ Compulsory |
___ Waiver (on the bill) |
___ Waiver (card only) |
| ___ Other (please explain) |
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____ Per attached specifications
____ Per attached student brochure with these benefits changes
Note Please attach your most recent insurance brochure and enrollment card.
___ Voluntary major medical plan, up to $1,000,000 benefit available
(designed to pick up where your base plan ends), with this deductible
- ___ $25,000
- ___ $30,000
- ___ $50,000
- ___ Other $___________
What was the individual student premium for the past three years?
- $___________________
- $___________________
- $___________________
Claim Data for the past three years, please provide these details
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Year |
Last Year |
Two Years Ago |
Three Years Ago |
| Total Premium |
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| Total Paid Claims |
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| Number of Students Insured |
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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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