Student Insurance, Athletic Accident Coverage, Special Risk Insurance, Summer Camps, Little Leagues

5071 WEST H AVENUE | KALAMAZOO, MI 49009 | 269.381.6630

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1st Agency: College Sports Information Request

FOR COLLEGE ADMINISTRATORS

INSTITUTION INFORMATION

Name of Institution *

Street Address *

City *

State *

Zip Code *

INFORMATION PROVIDED BY

Your Name *

Job Title *

Phone Number *

Email Address *

PLEASE INPUT NUMBER OF PARTICIPANTS FOR EACH SPORT:

FEMALE

MALE

FEMALE

MALE

FEMALE

MALE

FEMALE

MALE

Baseball

Basketball

Bowling

Cheerleaders

Competitive Cheer

Cross Country

Dance

Diving

Equestrian

Fencing

Football(Fall)

Football (Spring)

Field Hockey

Golf

Gymnastics

Ice Hockey

Lacrosse

Riflery

Rodeo

Rowing Crew

Sailing

Skiing

Soccer

Softball

Student Mgr/ Trainers

Swimming

Tennis

Track & Field(Indoor)

Track & Field(Outdoor)

Volleyball

Water Polo

Wrestling

OTHER SPORTS (Please list Male and Female Participants) :

AFFILIATION:

NCAA

NAIA

NJCAA

Other

Other Affiliation

PREVIOUS INSURANCE INFORMATION - CURRENT YEAR:

Please list information for 2019-2020 below.

Maximum Medical

Excess or Primary

Deductible

Benefit Period

Accidental Death Benefit

Coverage for Overuse Injuries / Conditions?

Yes No

Coverage for HMO / PPO Denials?

Yes No

Coverage for Heart / Circulatory Conditions?

Yes No

Coverage for Pre-Existing Conditions?

Yes No

Premium : Basic

Premium: Catastrophic

Number of Claims Paid

Amount of Claims Paid

Through (Date)

PREVIOUS INSURANCE INFORMATION - PAST THREE YEARS:

Please list information for 2018-2019 below.

Maximum Medical

Excess or Primary

Deductible

Benefit Period

Accidental Death Benefit

Coverage for Overuse Injuries / Conditions?

Yes No

Coverage for HMO / PPO Denials?

Yes No

Coverage for Heart / Circulatory Conditions?

Yes No

Coverage for Pre-Existing Conditions?

Yes No

Premium : Basic

Premium: Catastrophic

Number of Claims Paid

Amount of Claims Paid

Through (Date)

Please list information for 2017-2018 below.

Maximum Medical

Excess or Primary

Deductible

Benefit Period

Accidental Death Benefit

Coverage for Overuse Injuries / Conditions?

Yes No

Coverage for HMO / PPO Denials?

Yes No

Coverage for Heart / Circulatory Conditions?

Yes No

Coverage for Pre-Existing Conditions?

Yes No

Premium : Basic

Premium: Catastrophic

Number of Claims Paid

Amount of Claims Paid

Through (Date)

Please list information for 2016-2017 below.

Maximum Medical

Excess or Primary

Deductible

Benefit Period

Accidental Death Benefit

Coverage for Overuse Injuries / Conditions?

Yes No

Coverage for HMO / PPO Denials?

Yes No

Coverage for Heart / Circulatory Conditions?

Yes No

Coverage for Pre-Existing Conditions?

Yes No

Premium : Basic

Premium: Catastrophic

Number of Claims Paid

Amount of Claims Paid

Through (Date)

OPTIONS TO BE QUOTED:

If Other, please list:

Date Quote Needed:

Accidental Death Benefit

Please enter any other pertinent information you would like to add here:

CONTACT US

Address

5071 WEST H AVENUE | KALAMAZOO, MI 49009

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269.381.6630

Mail

1stAgency@1stAgency.com

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