General Information

Do you currently have any customers insured with Bollinger?	YesNo
Your First Name:
Your Last Name:
Your Phone #:
Company or Agency:
Your E-mail Address:
E-mail Address Confirmation:
E-mail Address must match!
Mailing Address:
Mailing Address 2:
City:
State:	AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OK OH OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:

This Quote is for the Following Customer

School Name:
Mailing Address:
Mailing Address 2:
City:
State:	AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OK OH OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:

Grade Structure:	Individual Elementary School Individual Junior or Senior High School K-12 School District K-6 District K-8 District Nursery School Other Regional High School District Vocational School District
Comments:

Coverage Plans

Compulsory Plan Option:	All students - all interscholastic sports EXCLUDING tackle football All students - all interscholastic sports INCLUDING tackle football All students - no interscholastic sports
Sports Only Plan Option:	All sports EXCLUDING interscholastic football All sports INCLUDING interscholastic football Only interscholastic football
Desired Effective Date:

Indicate any additional covered activities

Competitive cheer

Expanded sports medical

Field trips

Flag football

Gym classes

Heart and circulatory

Intramural sports

JROTC

Majorettes

Off-season conditioning

Overnight field trips

ROTC

Summer camp

Volunteers

Comments:

Enrollment and Census

Pre-K students:
Grades K-8:
Grades 9-12:
Total Enrollment:
# of Athletes:

Comments:

Base Coverage

Maximum Benefit:	$100,000 $25,000 $250,000 $50,000 Other
Deductible:	$100 $250 $500 Other
Coinsurance:	100% 70% 80% 90% Other
Benefit Period:	1 year 2 year 3 year Other
Benefit Payment:	Coordination of Benefits Full Excess Other Primary Primary Excess

Catastrophic Coverage

Maximum Benefit:	$1,000,000 $5,000,000 Other
Deductible:	$25,000 $50,000 Other
Benefit Period:	10 year 5 year Other
Benefit Payment:	Coordination of Benefits Full Excess Other Primary Primary Excess
Student Disability Amount:
Athletic Disability Amount:

Claim History

Is this a start up plan?

YesNo

Additional Comments: