CATASTROPHIC INSURANCE COVERAGE QUESTIONNAIRE

In order to present you with a proposal for your Catastrophic accident insurance for the coming year, we will need some information. Please fill out this form, return it to me, and we will have a firm fixed price proposal on this fine plan to you in a few days.

Name of School (District)_____________________________________________________________

Adress_____________________________________________________________________________

City___________________State__________Zip_______________Phone_______________________

Administrator responsible for Ins._________________________________________________

Grades included in School (District)_________________Number of High Schools (District)________

Do you insure all Students with Catastrophic coverage?  Yes____ NO____ Number of Students____________________________

Medical Limit Required   (  )$1,000,000    (  )$5,000,000    (  )$10,000,000

Catastrophic Cash Required         (  )NONE              (  ) $600,000                     (  )$1,200,

Deductible Required             (  ) $10,000               (  )$25,000            (  )$100,000           (  )$1,000,000

Please fill in below the number of participants during the current year, in the high school interscholastic sports sponsored by your school (district). If you have tackle football on a level below the high school freshman level, include that in the “other” column.

NOTE: If you insure ALL students, you need not fill out the form below.

SPORT

NUMBER

SPORT

NUMBER

BASEBALL

 

RIFLE

 

BASKETBALL

 

SKIING

 

BOWLING

 

SOCCER

 

CROSS COUNTRY

 

SOFTBALL

 

FENCING

 

SWIMMING

 

FIELD HOCKEY

 

TENNIS

 

FOOTBALL

 

TRACK

 

GYMNASTICS

 

VOLLEYBALL

 

GOLF

 

WEIGHTLIFTING

 

ICE HOCKEY

 

WRESTLING

 

LACROSSE

 

OTHER

 

We will be most happy to coordinate the program through your local agent or broker. If you wish to work with the broker, please provide the information below.

NAME OF AGENT OR BROKER___________________________________________________________

CONTACT__________________________________________PHONE____________________________

ADDRESS___________________________________CITY_________

BOB MC CLOSKEY INSURANCE
76 MAIN ST., PO BOX 511
MATAWAN, NJ 07747
1‑800‑445‑3126