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.
|
|
Student Accident and Sports Medical Expense Insurance
Quotation Request Form
Please give us the following details, so we can return a quote.
Name of School________________________________________________________
Street Address________________________________________________________
City________________________________State/Zip_________________________
Phone ( )_____________________
School Official
(your name) _________________________________
Your e-mail address ___________________@________________
Dates
Please list start and end dates
| Dates of School Year |
|
to |
| First Day of Football |
|
Last Day |
| Summer School |
|
to |
Anticipated Total Enrollment
| Anticipated Enrollment |
Total |
Number
of Athletes |
Pre K to 6 or 8
(circle one) |
|
|
Grades 6-8 or 7-9
(circle one) |
|
|
Grades 9-12 or 10-12
(circle one) |
|
|
| Boarding Students |
|
|
| Summer School |
|
|
Please check all that apply.
- All Students School Time
- All Students—No Sports
- All Students—All Sports, including Football*
- All Students—All Sports, no Football*
- Sports Coverage
- All Sports, including Football*
- All Sports, no Football*
- Football Only*
*Please complete the census, below.
School Sponsored and
Supervised Sport or Activity |
Number of
Senior High
Students |
Number of
Junior High
Students |
| Band |
|
|
| Baseball |
|
|
| Basketball |
|
|
| Cheerleading |
|
|
| Cross Country |
|
|
| Drama |
|
|
| Drill Team |
|
|
| Flag Corps |
|
|
Football
Varsity
Junior Varsity
Freshman
|
V
JV
F
|
V
JV
F |
Golf |
|
|
| Journalism |
|
|
| Math |
|
|
| Music |
|
|
| Pep Squad |
|
|
| Soccer |
|
|
| Softball |
|
|
| Swimming |
|
|
| Tennis |
|
|
| Track |
|
|
| Volleyball |
|
|
| Wrestling |
|
|
Other
|
|
|
Other
|
|
|
Experience for the past three years—please enclose copies of insurance brochure or policy, including rates being charged.
| |
Year |
Last Year |
Two Years Ago |
Three Years Ago |
| Company |
|
|
|
|
| Premium |
|
|
|
|
| Claims |
|
|
|
|
| Date |
|
|
|
|
| Paid To |
|
|
|
|
| Number of Students- Athletes |
|
|
|
|
| Rates |
|
|
|
|
Date proposal needed: ________________________
Thank you!
If you prefer, you can mail your quote request to us:
American Health Administrators
PO Box 4586
Seattle WA 98194
[ top ]
|
|