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Catastrophic Accident Medical K-12 Insurance Quote Form


 

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.

Catastrophic Accident Medical K-12
Quotation Request Form

Please give us the following details, so we can return a quote.

Name of School(s) ________________________________________________________
School Official
(your name) _________________________________
Your e-mail address ___________________@________________
Street Address________________________________________________________
City________________________________State/Zip_________________________
Phone (    )_____________________

Dates
Please list start and end dates

Dates of School Year                          to                         

Anticipated Total Enrollment

Anticipated Enrollment Total           Number
of Athletes
Pre K to 8    
Grades 9-12    
Boarding Students    

Plan Desired

Class Description Circle if True
Class I All enrolled students of the school in grades K-12 Exclude football
Class II All interscholastic athletes, including interscholastic football and cheerleading and participants of non-sport extracurricular activities of the school. Exclude football
Class III All interscholastic athletes, including interscholastic football, band members, cheerleaders, football majorettes, participants of intramural sports, gym classes and non-sport extracurricular activities of the school. Exclude football
Benefits
$5,000,000 Accident Medical (excess) Lifetime benefit period, $25,000 deductible with two years to satisfy deductible. Including allocated expense benefits.



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

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Last Update June 14
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