PRIVATE SCHOOL STUDENT/ATHLETIC ACCIDENT INSURANCE

QUESTIONNAIRE

In order to present you with a proper proposal for your student 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 School (District)____________________________________________________________________________________

Address____________________________________________________________________________________

Citv____________________State,__________________Zip____________________Phone_________________

Administrator responsible for Student Ins._________________________________________________________

Grades included in School________________Play Interscholastic Football?___________( )YES  ( )NO

Do you insure all Students? Yes ( ) NO ( )                      Number of Students____________

K‑6 (8)___________7(9)‑12__________

Boarding Students______________________Foreign Students_______________

Current Carrier (Administrator)______________________________________________________________

Premium & Losses
for the Past 3 years
Policy Year Premium Losses Paid
  $  
  $  
     
     

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____________

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