Personal Information:

* 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: *

I Am Interested In Receiving A Proposal For:

	Student Health Insurance:			Intercollegiate Athletic Insurance:
	Short Term or "In Between" Protection:			Dental Insurance for:
	International Student Coverage:
	Not covered Mandatory Voluntary
	Other

Student Health Insurance

In Order To Present You With The Lowest Possible Cost, Please Provide The Following Information:
Number of Students:			What % are Commuters?	%
Do you have an infirmary?	Yes No		Number of Beds Dispensary
Do you employ nurses? If so, what is their availability?
office hours full time

Current Coverage is:		Mandatory	Voluntary
	Year before Last	Last Year	Current Year
Dates (mm/yy)	to	to	to
No. of Insured Students:
Cost Per Student:
Total Premiums:
Claims Paid:

What agency handles your present plan?

If our plan proves interesting, what agency would you prefer for local service?

Do you wish our proposal to be:

mandatory voluntary waiver other

Shall We:

Mail the proposal to you? Have one of our representatives deliver the plan? Contact agent shown above?

Date:   Deadline: