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

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School Information:

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?
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Accepted file types: pdf, doc, docx, Max. file size: 256 MB.
Are you currently working with an insurance broker for accident and health coverage?
Are you currently working with a broker?
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].
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