Student Accident Insurance Request for Quote Form - Business/Group

Client Information
Do you currently have student accident insurance?
Do you currently have interscholastic sports?

Estimate the number of students:

Type of coverage
Please provide information on your current policy

Desired benefits: 

Select a choice
Maximum Benefit Period
Catastrophic 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 

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Great American Insurance Group

301 E. 4th Street

Cincinnati, OH 45202