College Activities Accident Insurance Request for Quote Form

School Information
Affiliation:
If applicable, please provide the number of participants by gender.

Previous Insurance Information:

Travel To/From:
Please provide coverage for: (select all that apply)
Select a choice
Maximum Benefit Period

Prior coverage:

is there a plan currently in force?
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?

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 [email protected] 

Powered by:

Great American Insurance Group

301 E. 4th Street

Cincinnati, OH 45202

[email protected]