Primary Insurance with Athletic Coverage Information Form

The Collegiate Sports Medicine Foundation would like to provide you access to primary insurance programs that have an athletic benefit.  These plans are from a variety of companies of which some are only available in certain areas.

Please complete the information form below and we will forward you the options available in your area.

School:

CityStateZip

Contact Person:

Phone:

Fax:

Email:

Does your university sponsor football? 

How many athletes would you anticipate needing insurance (approximate)?

Number of Domestic Needing Insurance(approximate):

Number of International Needing Insurance(approximate):

Who would be paying for the insurance?

Do you currently require student athletes to have primary insurance?

Does your current student health plan cover athletic injuries?

YesNo

SchoolStudent AthleteCombinationOther

YesNo

YesNo