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Home > Life > Student-Accident Quote Form
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Student-Accident Quote Form


Please complete the following form to begin the Student-Accident quoting process. If you prefer to email any of the below referenced information, please forward to Lauren Allen at lauren.allen@bbrown.com

Compensation Disclaimer Compensation Disclaimer.pdf



Request For Proposal
School Name or School District *
Street Address *
City *
State *
ZIP / Postal Code *
First Name *
Last Name *
E-Mail Address *
Phone Number *
Requested Effective Date for Quote *
/ /
CURRENT PLAN Mandatory/Blanket Coverage
Maximum Medical Benefit
Catastrophic Coverage

Total Number of High Schools
Total Number of Junior Highs
Current Benefit Plan Tier
Current Insurance Carrier
Claims & Premium Report
2020-2021 Premium Paid
2020-2021 Claims Paid
2019-2020 Premium Paid
2019-2020 Claims Paid
2018-2019 Premium Paid
2018-2019 Claims Paid
Catastrophic Coverage
Catastrophic/Optional CASH Coverage


Class I: All enrolled students of the School/School District including all sports & activities.
Class II: All interscholastic sports, including interscholastic football and cheerleading.
Class III: All interscholastic sports, including interscholastic football, band cheerleading, majorettes, intramural sports, gym classes, and non-sport extracurricular activities.
Based upon the above description, which Class (I, II, or III) do you need for Catastrophic Coverage


Additional Comments
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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