5071 WEST H AVENUE | KALAMAZOO, MI 49009 | 269.381.6630
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1st Agency: Student Health Request for Information



RESPONSIBLE SCHOOL OFFICIAL


TYPE OF PLAN

Check all applicable. Please include a brochure of your present Student Health Plan.


Plans:

https://www.1stagency.com/forms/shrfif.php

PREMIUM RATES

Indicate rates charged for the current and past three years.


ALTERNATE QUOTES

Based on your current plan, would you like additional quotes to increase, decrease or add specific benefits, i.e. Room & Board, Mental & Nervous? If so, please specify.


HEALTH SERVICE INFORMATION