Dissinger Reed: Insurance, Consulting, Risk Management

Intercollegiate Secondary Athletic Insurance Quotation Request Form

School Information

Name of Institution

Public Private
Division NCAA I NCAA II NCAA III NAIA NJCAA Other
Address
City

State

Zip
Contact Name

Title
Phone

Fax
Best Time to Call AM PM Any
E-mail

Part A: Covered Intercollegiate Participants

Sport	Men	Women
Archery	Archery (Men)	Archery (women)
Badminton	Badminton (Men)	Badminton (Women)
Band	Band (Men)	Band (Women)
Baseball	Baseball (Men)	Baseball (Women)
Basketball	Basketball (Men)	Basketball (Women)
Bowling	Bowling (Men)	Bowling (Women)
Boxing	Boxing (Men)	Boxing (Women)
Cheerleading	Cheerleading (Men)	Cheerleading (Women)
Cricket	Cricket (Men)	Cricket (Women)
Cross Country	Cross Country (Men)	Cross Country (Women)
Cross Country Skiing	Cross Country Skiing (Men)	Cross Country Skiing (Women)
Cycling	Cycling (Men)	Cycling (Women)
Drill Team	Drill Team (Men)	Drill Team (Women)
Equestrian	Equestrian (Men)	Equestrian (Women)
Fencing	Fencing (Men)	Fencing (Women)
Field Hockey	Field Hockey (Men)	Field Hockey (Women)
Football (Fall)	Football (Fall) (Men)	Football (Fall) (Women)
Football (Spring)	Football (Spring) (Men)	Football (Spring) (Women)
Golf	Golf (Men)	Golf (Women)
Gymnastics	Gymnastics (Men)	Gymnastics (Women)
Ice Hockey	Ice Hockey (Men)	Ice Hockey (Women)
Karate/Judo	Karate/Judo (Men)	Karate/Judo (Women)
Lacrosse	Lacrosse (Men)	Lacrosse (Women)
Racquetball	Racquetball (Men)	Racquetball (Women)

Sport	Men	Women
Riflery	Riflery (Men)	Riflery (Women)
Rodeo	Rodeo (Men)	Rodeo (Women)
Rowing/Crew	Rowing/Crew (Men)	Rowing/Crew (Women)
Rugby	Rugby (Men)	Rugby (Women)
Sailing	Sailing (Men)	Sailing (Women)
Skiing	Skiing (Men)	Skiing (Women)
Soccer	Soccer (Men)	Soccer (Women)
Softball	Softball (Men)	Softball (Women)
Student Coaches	Student Coaches (Men)	Student Coaches (Women)
Student Managers	Student Managers (Men)	Student Managers (Women)
Student Trainers	Student Trainers (Men)	Student Trainers (Women)
Syncronized Swim	Syncronized Swim (Men)	Syncronized Swim (Women)
Swimming/Diving	Swimming/Diving (Men)	Swimming/Diving (Women)
Tennis	Tennis (Men)	Tennis (Women)
Track and Field	Track and Field (Men)	Track and Field (Women)
Ultimate Frisbee	Ultimate Frisbee (Men)	Ultimate Frisbee (Women)
Volleyball	Volleyball (Men)	Volleyball (Women)
Water Polo	Water Polo (Men)	Water Polo (Women)
Wrestling	Wrestling (Men)	Wrestling (Women)
	Other (Listed Below)
Other Sport 1	Other Sport 1 (Men)	Other Sport 1 (Women)
	Other Sport 2 (Men)	Other Sport 2 (Women)
	Other Sport 3 (Men)	Other Sport 3 (Women)
	Other Sport 4 (Men)	Other Sport 4 (Women)

	Men	Women
Totals	0	0

Part B: Previous Insurance Information

Benefits	2007-08	2008-09	2009-10	Current Year to Date
Medical Maximum Limit	Medical Maximum Limit - 3 Years Previous	Medical Maximum Limit - 2 Years Previous	Medical Maximum Limit - 1 Years Previous	Medical Maximum Limit - Current Year
Excess or Primary	Excess or Primary - 3 Years Previous	Excess or Primary - 2 Years Previous	Excess or Primary - 1 Years Previous	Excess or Primary - Current Year
Benefit Period (# of Weeks)	Benefit period - 3 Years Previous	Benefit period - 2 Years previous	Benefit period - 1 Years previous	Benefit period - Current Year
Accidental Death and Dismemberment Benefit	Accidental Death and Dismemberment Benefit - 3 Years Previous	Accidental Death and Dismemberment Benefit - 2 Years Previous	Accidental Death and Dismemberment Benefit - 1 Years Previous	Accidental Death and Dismemberment Benefit - Current Year
Deductible	Deductible - 3 Years Previous	Deductible - 2 Years Previous	Deductible - 1 Years Previous	Deductible - Current Year
Coverage for Overuse Injuries/Conditions	Coverage for overuse injuries/conditions - 3 Years Previous	Coverage for overuse injuries/conditions - 2 Years Previous	Coverage for overuse injuries/conditions - 1 Years Previous	Coverage for overuse injuries/conditions - Current Year
Coverage for HMO/PPO Denials	Coverage for HMO-PPO Denials - 3 Years Previous	Coverage for HMO-PPO Denials - 2 Years Previous	Coverage for HMO-PPO Denials - 1 Years Previous	Coverage for HMO-PPO Denials - Current Year
Coverage for Re-injury/Pre-existing Conditions	Coverage for Re-injury - 3 Years Previous	Coverage for Re-injury - 2 Years Previous	Coverage for Re-injury - 1 Years Previous	Coverage for Re-injury - Current Year
Coverage for Heart/Circulatory	Coverage for Heart/Circulatory - 3 Years Previous	Coverage for Heart/Circulatory - 2 Years Previous	Coverage for Heart/Circulatory - 1 Years Previous	Coverage for Heart/Circulatory - Current Year
Guest Recruit Coverage	Guest Recruits - 3 Years Previous	Guest Recruits - 2 Years Previous	Guest Recruits - 1 Years Previous	Guest Recruits - Current Year
Premium
Basic	Basic Premium - 3 Years Previous	Basic Premium - 2 Years Previous	Basic Premium - 1 Years Previous	Basic Premium - Current Year
Claims History **
Number of Claims Paid	Number of Claims Paid - 3 Years Previous	Number of Claims Paid - 2 Years Previous	Number of Claims Paid - 1 Years Previous	Number of Claims Paid - Current Year
Total Amount of Claims Paid	Total Amount of Claims Paid - 3 Years Previous	Total Amount of Claims Paid - 2 Years Previous	Total Amount of Claims Paid - 1 Years Previous	Total Amount of Claims Paid - Current Year
As of (mm/dd/yyyy)	Claims Paid as of (date) - 3 Years Previous	Claims Paid as of (date) - 2 Years Previous	Claims Paid as of (date) - 1 Years Previous	Claims Paid as of (date) - Current Year
Insurance Carrier Name	Insurance Carrier Name - 3 Years Previous	Insurance Carrier Name - 2 Years Previous	Insurance Carrier Name - 1 Years Previous	Insurance Carrier Name - Current Year
** You will be required to submit carrier loss reports for all years dated no earlier than 3/1 of the current year.

Part C: Questions

What percentage of your student athletes have primary medical coverage?	Percentage of athletes with medical coverage
Do you have a certified athletic trainer on staff?	Certified Athletic Trainer on Staff
Does the athletic department routinely obtain information about student athletes' other insurance coverage?	Does athletic department get info on athlete's other coverage

Part D: Requested Benefit Options

Deductible

Deductible: $0 Deductible: $250 Deductible: $500 Deductible: $1,000 Deductible: $1,500 Deductible: $2,500 Deductible: $5,000

Other

Other

Other
Coverage for overuse/conditions Yes No
Coverage for HMO/PPO denials Yes No
Coverage for re-injury/aggravation Yes No
Coverage for heart and circulatory Yes No
Coverage for guest recruits Yes No
Accidental Death and Dismemberment

Accidental Death and Dismemberment: $10,000 (included) Accidental Death and Dismemberment: $25,000 Accidental Death and Dismemberment: $50,000 Accidental Death and Dismemberment: $100,000

Other
Would you like to see a quote for the following plans?

Fully Insured Plan

Self-Funding/Aggregate Deductible

Expanded Cheerleading Coverage

Primary Athletic Insurance

International Student Athlete Insurance

Part E: Comments Please add any comments

Quote Needed By: (mm/dd/yyyy)
Desired Effective Date: (mm/dd/yyyy)