Gary Financial Group

STUDENT ATHLETIC INSURANCE QUOTATION REQUEST

NAME OF SCHOOL:

ADDRESS:

CITY/STATE/ZIP:

YOUR NAME:

TITLE:

PHONE:

FACSIMILE:

DATE QUOTATION NEEDED BY:

APPROXIMATE NUMBER OF ATHLETES:

NUMBER PARTICIPATING IN EACH SPORT

PAST YEAR EXPERIENCE-VITAL FOR QUOTATION

COVERAGE REQUESTED

MEDICAL MAXIMUM:

DEDUCTIBLE:

SPECIAL REQUESTS/CONCERNS:

DOES YOUR PRESENT (OR PAST) COVERAGE HAVE ANY SPECIAL CONDITIONS, SUCH AS, EXPANDED MEDICAL OPTION, HMO/PPO OPTIONS? IS SO, WHICH ONES:

DOES YOUR CURRENT PREMIUM INCLUDE CATASTROPHIC ACCIDENT COVERAGE?

Yes No