Our Products
- Player Protect
- Season Saver
Sports Parents
- Get Covered
- Customer Log In
- Football
- Cheer
- Volleyball
- Baseball
- Softball
- Soccer
- Basketball
- Track & Field
- Gymnastics
- Winter Sports
- Water Sports
- Other Sports
Work With Us
Schedule a Demo
Claims
About
Customer Log In

Select Page

* required field

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

Requested Effective Date of Coverage

Quote Due Date

MM slash DD slash YYYY

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

MM slash DD slash YYYY

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

Accepted file types: pdf, doc, docx, Max. file size: 256 MB.

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

Yes

No

This field is hidden when viewing the form

Are you currently working with a broker?

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 [email protected].

Initial to agree to the above statement.

Date

MM slash DD slash YYYY

CAPTCHA

Powered by:

Great American Insurance Group

301 E. 4th Street

Cincinnati, OH 45202

[email protected]

MAIN OFFICE

300 E. Main Street, Suite 314 Charlottesville, VA 22902

1.800.475.2691

CORPORATE OFFICE

301 E 4th St. Cincinnati, OH 45201

GENERAL INQUIRIES

[email protected]

TECH SUPPORT

[email protected]

BROKER RELATIONS

[email protected]

CLAIMS

[email protected]

UNDERWRITING

[email protected]

MARKETING & COMMUNICATIONS

[email protected]

Terms & Conditions
Privacy
Cookie Policy
Sitemap

© 2025 Great American Insurance Company. All Rights Reserved. Great American Insurance Group’s member companies are subsidiaries of American Financial Group, Inc. (AFG). AFG is a holding company whose common stock is listed on the New York Stock Exchange. Policies are underwritten by Great American Insurance Company, an authorized insurer in all 50 states and the DC.