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Student Insurance Information Inquiry form
Contact Person: *  
School Name: *
Address: *  
Address 2nd line  
City: *  
State: *  
Zip: *  
Phone Number: *  
Fax Number:  
Daytime Phone Number: *  
E-mail: *  
ANNUAL PREMIUM RATE INFORMATION    
Annual Published Rate:  
Total Premium Collected:  
Total Insured Students
Student Only Rate:    
Current Year
Last School Year
ELIGIBILITY INFORMATION  
Is student coverage:
Mandatory (included in tuition, and student is responsible for payment)

Voluntary (students may enroll by choice, but are not required to purchase insurance)

Hard Waiver (included in tuition, but charge can be removed once student provides proof of other coverage)

Is coverage available to Part-Time Students?

Yes

Is Dependent Coverage offered:

 Yes

What would you liked changed in your current plan design:

Thank you for taking the time to complete this questionnaire. The more detailed information you provide, the better we will be able to understand your student insurance needs, and will be able to develop a responsive proposal. We may be in touch with you should we need additional information.

 

We offer a combination of Student health insurance, short term health insurance, permanent health insurance, dental insurance, short term medical insurance, international health insurance, travel insurance, college student health insurance, life insurance and term life insurance.
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