Sports Accident Coverage

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Intercollegiate Sports Insurance

Please consider Macori, Inc. when you solicit bids or request proposals for your Athletic Coverage. Our quotes are competitive and our service is personalized to meet your department's specific needs. We are able to bid according to your specifications or to work with your program to design a new plan.

Macori has 20+ years experience exclusively in the Student Insurance business and our staff is familiar with the special needs of college athletic programs.

We look forward to receiving your information. Please complete and return the questionnaire below or add us to your list of prospective bidders.

Basic Athletics Injury Insurance Program Quotation Request Form For: Intercollegiate Sports (Club/Intramural Sports Insurance also available)
(All the fields marked with * are mandatory)
Date Completed*
Name of School*
Address*
City*
State*
Zip Code*
Email*
Information Provided by*
Title*
Phone*
Fax*

Sports	Number of Participants		Sports	Number of Participants
	Male	Female		Male	Female
Archery			Judo
Badminton			Karate
Band			Lacrosse
Baseball			Racquetball
Basketball			Riflery
Bowling			Rodeo
Boxing			Rowing
Cheerleading			Rugby
Crew			Sailing
Cross Country			Skiing
Cycling			Soccer
Diving			Softball
Drill Team			Squash
Equestrian			Swimming
Fencing			Tennis
Field Hockey			track & Field
Football - Fall Only			Volleyball
Football - Spring Only			Water Polo
Golf			Wrestling
Gymnastics			Other Club/ Intramural? Please add below or by separate list
Ice Hockey

PREVIOUS INSURANCE INFORMATION	200 / 200	200/ 200	200/ 200
1. Maximum Medical Coverage	$	$	$
2. Accidental Death & Dismemberment Benefit	$	$	$
3. Dental Benefit	$	$	$
4. Deductible Amount	$	$	$
5. "Disappearing" or "Corridor" Deductible (choose one) a. Disappearing - allows payments by other insurance to satisfy the deductible. b. Corridor - does not allow payments by other insurance to satisfy the deductible.
6. Program pays excess or primary to other insurance
7. Benefit Period (1,2, or 3 years)
8. Expanded Medical Benefit? (Yes or No) Adds coverage for sports-related conditions, such as tendonitis, bursitis, stress fractures, etc.
9. Pre-existing conditions covered? (Yes or No)
10. HMO/PPO Supplement Benefit (Yes or No) Adds Coverage for expenses incurred when primary HMO/PPO facility denies coverage.
11. Coinsurance (Yes or No) If "Yes", please indicate whether 70%, 80%, or 90%
12. Are you a NCAA member institution?
13. Premium	$	$	$
14. Dollar Amount of Claims Paid by Athletic Insurance and paid through what date (month/ year).	$ Date	$ Date	$ Date
15. Number of claims paid
16. Name of Insurance Carrier
17. Name of Agent/ Agency
18. Percentage of athletes with collectible insurance.	%	%	%

Proposal Request:

1. Quote current year plan benefits ("as is")? (Please provide a copy of the current policy via email, mail, or fax.)

Yes No

2. Quote current year plan with the following benefit changes or deductible:

3. Date quote needed by:

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