Home
Why AIP
Our Partners
Privacy Policy
Insurance Basics
Student Health Fair
Contact AIP
Need Assistance? 800-452-5772
Online Request for Intercollegiate Athletic Insurance
*
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
*
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:
Please Select
On Staff
On Retainer
Other
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.
© 2011 Associated Insurance Plans International, Inc. | All rights Reserved |
Privacy Policy and HIPAA (Health Insurance Portability and Accountability Act) Compliance