COLLEGE STUDENT ACCIDENT AND SICKNESS

QUESTIONNAIRE

NAME OF COLLEGE OR UNIVERSITY____________________________________________________
ADDRESS____________________________________________________________________________
CITY ______________________________________________STATE___________ ZIP______________
STUDENT CENSUS___________________________________________________
FULL TIME__________________MEN_________WOMEN______TOTAL________
PART TIME__________________MEN_________WOMEN______TOTAL________


PREMIUM AND LOSS EXPERIENCE-3 YEARS

 YEAR

TOTAL PREMIUM

PAID LOSSES

NO. INSURED

 CURRENT YEAR      
       
       
       
 

PREMIUM RATES-3 YEARS

  YEAR STUDENT

STUD. AND
SPOUSE

STUD./SPOUSE
CHILDREN

 CURRENT YEAR      
       
       
       

PLEASE ENCLOSE A BROCHURE, OF YOUR PLAN FOR THE PAST 3 YEARS

WHAT IS YOUR CURRENT METHOD OF ENROLLMENT??
COMPULSORY _______WAIVER(  )  VOLUNTARY (  )
DO YOU WANT ANY INTERCOLLEGIATE SPORTS COVERAGE?  YES(  ) No(  )
PERSON RESPONSIBLE FOR STUDENT A & S INSURANCE:_________________________

NAME_________________________________________________________________________

TITLE__________________________PHONE_________________________________________

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