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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Intercollegiate Sports 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 ( )_____________________
College Official
(your name and title) _________________________________, ______________
Your e-mail address ___________________@________________
| Intercollegiate Sport |
Number of
Male
Participants |
Number of
Female
Participants |
| Archery |
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| Badminton |
|
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| Bank |
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| Baseball |
|
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| Basketball |
|
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| Bowling |
|
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| Boxing |
|
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| Cheering |
|
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| Crew |
|
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| Cross country |
|
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| Diving |
|
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| Drill team |
|
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| Equestrian |
|
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| Fencing |
|
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| Field hockey |
|
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| Flag football |
|
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| Football—Fall only |
|
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| Football—Spring only |
|
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| Golf |
|
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| Gymnastics |
|
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| Ice hockey |
|
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| Intramural sports |
|
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| Judo |
|
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| Karate |
|
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| Lacrosse |
|
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| Racquet ball |
|
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| Riflery |
|
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| Rowing |
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| Rugby |
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| Sailing |
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| Skiing |
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| Soccer |
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| Softball |
|
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| Squash |
|
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| Swimming |
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| Tennis |
|
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| Track & Field |
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| Volleyball |
|
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| Water ballet |
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| Water polo |
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| Wrestling |
|
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| Other ________ |
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Current Details
Please give us these additional details:
- Current insurance carrier _____________________________
- Current medical expense limit _____________________________
- Current Accidental Death
and Dismemberment Benefit $_____________
- Current plan deductable $_____________
- Affiliation and Division (please circle both)
| NCAA |
NCIA |
NACDA |
Other _______ |
| I |
II |
III |
Other _______ |
Claims Experience Please provide claims experience for the past three years, to be eligible for a quotation
For Academic Year
Current and two prior years |
Program Deductible |
Premium Paid |
Paid Claims |
Pending Claims |
| 20__ to 20 __ |
|
|
|
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| 20__ to 20 __ |
|
|
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| 20__ to 20 __ |
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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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