College Activities Accident Insurance Request for Quote Form - Business/Group

Requested Effective Date of Coverage

Quote Due Date

School Information

Company

Name

Email

Address

City

State

Zip

Website

Affiliation:

NCAA
NAIA
NJCAA
OTHER

Division

If applicable, please provide the number of participants by gender.

Archery - Total

Badminton - Total

Band - Total

Baseball - Total

Crew - Total

Cross Country Running - Total

Dance - Total

Drill Team - Total

Diving - Total

Equestrian - Total

Fencing - Total

Field Hockey - Total

Football (Tackle) - Total

Football (Flag/Touch) - Total

Golf - Total

Gymnastics - Total

Handball - Total

Ice Hockey - Total

Lacrosse - Total

Mascots - Total

Martial Arts - Total

Racquetball - Total

Riflery - Total

Rodeo - Total

Rowing - Total

Rugby - Total

Sailing - Total

Skiing (Downhill) - Total

Skiing (Cross Country) - Total

Soccer - Total

Softball - Total

Squash - Total

Swimming - Total

Table Tennis - Total

Tennis - Total

Track & Field (indoor) - Total

Track & Field (outdoor) - Total

Volleyball - Total

Water polo - Total

Weightlifting - Total

Wrestling - Total

Other - Total

Previous Insurance Information:

Current Carrier

Current Deductible

Current Max Medical

Current Benefit Period

Current Dental Limit

Current AD&D

Current AD&D Aggregate Limit

Current Expanded Injury

Current HMO/PPO

Current Pre-Exisiting

Current Heart & Circulatory

Current Guest & Recruit

Current Premium Paid

Current Claims Paid

Current Paid As Of Date

One Year Prior Carrier

One Year Prior Deductible

One Year Prior Max Medical

One Year Prior Benefit Period

One Year Prior Dental Limit

One Year Prior AD&D

One Year Prior AD&D Aggregate Limit

One Year Prior Expanded Injury

One Year Prior HMO/PPO

One Year Prior Pre-Existing

One Year Prior Heart & Circulatory

One Year Prior Guest & Recruit

One Year Prior Premium Paid

One Year Prior Claims Paid

One Year Prior Paid As Of Date

Two Years Prior Carrier

Two Years Prior Deductible

Two Years Prior Max Medical

Two Years Prior Benefit Period

Two Years Prior Dental Limit

Two Years Prior AD&D

Two Years Prior AD&D Aggregate Limit

Two Years Prior Expanded Injury

Two Years Prior HMO/PPO

Two Years Prior Pre-Existing

Two Years Prior Heart & Circulatory

Two Years Prior Guest & Recruit

Two Years Prior Premium Paid

Two Years Prior Claims Paid

Two Years Prior Paid As Of Date

Three Years Prior Benefit Period

Three Years Prior Deductible

Three Years Prior Max Medical

Three Years Prior Carrier

Three Years Prior Dental Limit

Three Years Prior AD&D

Three Years Prior AD&D Aggregate Limit

Three Years Prior Expanded Injury

Three Years Prior HMO/PPO

Three Years Prior Pre-Existing

Three Years Prior Heart & Circulatory

Three Years Prior Guest & Recruit

Three Years Prior Premium Paid

Three Years Prior Claims Paid

Three Years Prior Paid As Of Date

Four Years Prior Benefit Period

Four Years Prior Deductible

Four Years Prior Carrier

Four Years Prior Max Medical

Four Years Prior Dental Limit

Four Years Prior AD&D

Four Years Prior AD&D Aggregate Limit

Four Years Prior Expanded Injury

Four Years Prior HMO/PPO

Four Years Prior Pre-Existing

Four Years Prior Heart & Circulatory

Four Years Prior Guest & Recruit

Four Years Prior Premium Paid

Four Years Prior Claims Paid

Four Years Prior Paid As Of Date

Please provide any information on sports changes (added/removed)

Travel To/From:

Yes
No

Accidental Death

Accidental Dismemberment

Accidental Paralysis

Accidental Medical Expense

Deductible

Please provide coverage for: (select all that apply)

Pre-exisiting conditions
HMO/PPO denials
Expanded Medical
Heart & Circulatory
Dental Coverage
Guest & Recruit

Select a choice

Excess
Primary

Maximum Benefit Period

52 weeks
104 weeks

Other Benefits Requested:

Aggregate limit per occurrence (standard is 10 times the Accidental Death benefit)

Prior coverage:

is there a plan currently in force?

Yes
No

If yes, please provide carrier name:

Effective date

Please provide us with a copy of the current effective policy, premium, and lost history for the last three years.

Are you currently working with an insurance broker for accident and health coverage?

Yes
No

If yes, please provide insurance agency/broker name and contact information

I here by acknowledge that all answers and statements contained on this form are complete and accurate. I also understand that no coverage will become effective until an application has been approved by the Company.

Please email any attachments to underwriting@getpomi.com.

Initial to agree to the above statement.

Date

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Great American Insurance Group

301 E. 4th Street

Cincinnati, OH 45202

underwriting@getpomi.com