* Required Fields

First Name*		Last Name*

Title*		College or University*

Address

Address 2

City		State		Zip
		AK AL AR AZ CA CO CT DC DE GA HI IA ID IL IN KS KY MA MD ME MI MN MO MS MT NC NC ND NE NJ NM NV NY OH OK OR PA RI SC TN TX UT VA VT WA WI WV WY

Phone*		Fax
- -		- -

E-mail*

List any athletic conference in which you participate

Number of Insured Persons Per Sport* Sport Male Female Total Band Baseball Basketball Cheerleading Cross Country Equestrian Fencing Field Hockey Football (Fall) Football (Spring)  Golf Gymnastics Ice Hockey Lacrosse

Sport Male Female Total Rodeo Rugby Skiing Soccer Softball Student Managers  Swimming/Diving Tennis Track and Field Trainers Volleyball Wrestling Other

Complete up to date claim and policy information is required to obtain an accurate quotation.
Policy Year*	Current Year	Prior Year	Prior Year	Prior Year
Carrier
Deductible
Medical Expense Maximum
Benefit Period
Dental Limit
AD&D Claims Paid
Expanded Injury
HMO/PPO
Pre-Existing
Premium Paid
Claims Paid
Paid as of Date
Number of Claims Paid

Is your deductible administered and paid by athletic department funds?	Yes No
Team Physician:	Please Select On Staff On Retainer Other
Does your Student Accident & Health Policy provide for sports injuries?	Yes No
If yes, what is the maximum amount they will cover?
Deadline for receipt of proposal.