COLLEGE ATHLETIC ACCIDENT INSURANCE QUESTIONNAIRE

In order to present you with a proper proposal for your athletic 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 College or University:________________________________________________________________

Address:____________________________________________________________________________________

City:_____________________State:_________Zip:________Phone:___________________________________

Administrator responsible for Sports Accident Ins.:_______________________________________________

Current Carrier (Administrator) _________________________________________________________________

 
 
Premium and Losses
(for the past 3 years)
Company Policy Year Premium Deductible Losses Paid
         
         
         
         

Would you consider other deductible options other than those above?  YES____   NO_____

 Please fill in below the number of participants during the current year, in the intercollegiate sports program sponsored by your college.

SPORT MALE FEMALE

SPORT           

MALE FEMALE
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:_____________State:___________Zip:_____


We can also provide coverage for intramural and club sport activities, and accident and liability insurance for any CAMPS sponsored by the college or any of the athletic department personnel.

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