Free Quote Step 1 of 6 16% Name of School*Affiliation/Division:*Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information Provided By:PhoneFax: Number of ParticipantsMenWomenTotal # of Participants Previous Insurance Information2020 - '21DeductibleMedical MaximumBenefit PeriodAD&DPremium# Claims PaidAmount of Benefits PaidName of Insurance CompanyName of Claims Payor/TPA 2021 - '22DeductibleMedical MaximumFull Coverage for HMO/PPO DenialsYesNoFull Coverage for Pre-existing ConditionsYesNoBenefit PeriodAD&DPremium# Claims PaidAmount of Benefits PaidName of Insurance CompanyName of Claims Payor/TPA 2022 - '23DeductibleMedical MaximumFull Coverage for Expanded Medical(wear and tear injuries)YesNoFull Coverage for Heart & CirculatoryYesNoFull Coverage for HMO/PPO DenialsYesNoFull Coverage for Pre-existing ConditionsYesNoBenefit PeriodAD&DPremium# Claims PaidAmount of Benefits PaidName of Insurance CompanyName of Claims Payor/TPA 2023 - '24DeductibleMedical MaximumFull Coverage for Expanded Medical(wear and tear injuries)YesNoFull Coverage for Heart & CirculatoryYesNoFull Coverage for HMO/PPO DenialsYesNoFull Coverage for Pre-existing ConditionsYesNoBenefit PeriodAD&DPremium# Claims PaidAmount of Benefits PaidName of Insurance CompanyName of Claims Payor/TPAIn order to obtain quotes, we must have copies of your detailed, loss/claims reports for the last 4 years (back to 12-13) (true losses-excluding admin fees) This iframe contains the logic required to handle Ajax powered Gravity Forms.