Athletic Medical Insurance Quotation Request Form

Name of Institution:				NJCAANCCAAOtherI
Address:
City:		State:	Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR OT PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip:
Contact Name:		Title:
Daytime Phone:		Fax:
Contact Email:

 

Part A - COVERED INTERCOLEGIATE PARTICIPANTS:
SPORT	MEN	WOMEN		SPORT	MEN	WOMEN
BAND				SKIING
BASEBALL				SOCCER
BASKETBALL				SOFTBALL
CHEERLEADING				STUDENT COACHES
CROSS COUNTRY				STUDENT MANAGERS
DRILL TEAM				STUDENT TRAINERS
EQUESTRIAN				SWIMMING/DIVING
FIELD HOCKEY				TENNIS
FOOTBALL (FALL)				TRACK & FIELD
FOOTBALL (SPRING)				VOLLEYBALL
GOLF				WATER POLO
GYMNASTICS				WRESTLING
ICE HOCKEY				OTHER (LISTED BELOW)
LACROSSE
RIFLERY
RODEO
ROWING/CREW
RUGBY

 

Part B - PREVIOUS INSURANCE INFORMATION:
BENEFITS	3 YEARS PREVIOUS	2 YEARS PREVIOUS	1 YEARS PREVIOUS	CURRENT YEAR
Medical Maximum Limit
Excess or Primary	Excess Primary	Excess Primary	Excess Primary	Excess Primary
Deductible  ReducingCorridor
Benefit Period (# of Weeks)	52 104 156	52 104 156	52 104 156	52 104 156
Accidental Death Benefit
Coverage for overuse injuries/conditions	Yes No	Yes No	Yes No	Yes No
Coverage for HMO/PPO denials	Yes No	Yes No	Yes No	Yes No
Coverage for re-injury/re-aggravation	Yes No	Yes No	Yes No	Yes No
Coverage for Heart & Circulatory	Yes No	Yes No	Yes No	Yes No
Insurance Carrier Name
PREMIUM
Basic
Catastrophic
CLAIMS HISTORY **
Number of Claims Paid
Total Amount of Claims Paid
As of (mm/dd/yyyy)

** YOU WILL BE REQUIRED TO SUBMIT CARRIER LOSS REPORTS FOR ALL YEARS DATED NO EARLIER THAN 3/1 OF THE CURRENT YEAR.

Part C - QUESTIONS:
1. What percentage of your student-athletes have primary medical coverage?
2. Do you have a Certified Athletic Trainer on staff?	YesNo
3. Does the Athletic Department routinely obtain information about the student-athletes' other insurance coverage?	YesNo

 

Part D - OPTIONS:
Deductible: $0$250$500$1,000$1,500$2,500$5,000  Other:  Other:  Other:
Coverage for overuse injuries/conditions:	YesNo
Coverage for HMO/PPO denials:	YesNo
Coverage for re-injury/re-aggravation:	YesNo
Coverage for heart & circulatory:	YesNo
Accidental Death & Dismemberment Benefit: $10,000 (included)$25,000$50,000$100,000  Other:
Would you like to also see a quote for the following plans?	Self-Funding/Aggregrate Deductible Expanded Cheerleading Coverage

 

Part E - COMMENTS:

Please add any comments: (255 char. max)

 
 

QUOTE NEEDED BY: (mm/dd/yyyy)
DESIRED EFFECTIVE DATE: (mm/dd/yyyy)

 

Please indicate which office will need to receive your quotation request:
	Overland Park Office 7400 College Boulevard, Suite 100 Overland Park, KS 66210 Phone: 866-528-6222 Fax: 913-327-0201 Janice Briggs, Angela King or Jeff Struckle		Salt Lake City Office 2180 South 13000 East, SUite 520 Salt Lake City, UT 84106 Phone: 866-528-6222 Fax: 801-412-2625 Kathy Polanshek or Carol Malouf