Associated Insurance Plans International, Inc. The Worldwide Student Insurance Specialist with The Personal Touch!
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    Online Request for Intercollegiate Athletic Insurance    
   

* Required Fields

First Name*   Last Name*
Title*   College or University*
Address
Address 2
City   State   Zip
Phone*   Fax
- - - -
E-mail*
List any athletic conference in which you participate

Number of Insured Persons Per Sport*
Sport Male Female Total
Band
Baseball
Basketball
Cheerleading
Cross Country
Equestrian
Fencing
Field Hockey
Football (Fall)
Football (Spring) 
Golf
Gymnastics
Ice Hockey
Lacrosse
 
 
Sport Male Female Total
Rodeo
Rugby
Skiing
Soccer
Softball
Student Managers 
Swimming/Diving
Tennis
Track and Field
Trainers
Volleyball
Wrestling
Other

Complete up to date claim and policy information is required to obtain an accurate quotation.
Policy Year* Current Year Prior Year Prior Year Prior Year
Carrier
Deductible
Medical Expense Maximum
Benefit Period
Dental Limit
AD&D Claims Paid
Expanded Injury
HMO/PPO
Pre-Existing
Premium Paid
Claims Paid
Paid as of Date
Number of Claims Paid

Is your deductible administered and paid by athletic department funds? Yes No
Team Physician:
Does your Student Accident & Health Policy provide for sports injuries? Yes No
If yes, what is the maximum amount they will cover?
Deadline for receipt of proposal.