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)_____________________________________________________________
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.
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___________________________________________________________
BOB MC CLOSKEY INSURANCE