Francis L. Dean & Associates
Mandatory Underwriting Information

(Failure to submit the following information will delay and/or prevent release of quotation.)

	00-01	01-02	02-03	03-04
Previous Insurance Co.:	______________	______________	______________	______________
Coverage Type (Excess/Primary):	______________	______________	______________	______________
Medical Expense Benefit:	$ ____________	$ ____________	$ ____________	$ ____________
Accidental Death & Dismemberment Benefit:	$ ____________	$ ____________	$ ____________	$ ____________
Deductible:	$ ____________	$ ____________	$ ____________	$ ____________

Benefit Period: (1Yr/2Yr/3Yr)	______________	______________	______________	______________
Expanded Medical Coverage: (Y/N)	______________	______________	______________	______________
HMO/PPO Denial Coverage:(Y/N)	______________	______________	______________	______________
Pre-Existing Conditions Coverage: (Y/N)	______________	______________	______________	______________
Heart/Circulatory Coverage: (Y/N)	______________	______________	______________	______________
Premium Paid:	$ ____________	$ ____________	$ ____________	$ ____________
Claims Paid:	$ ____________	$ ____________	$ ____________	$ ____________
	As of ____/____ (Month) (Year)	As of ____/____ (Month) (Year)	As of ____/____ (Month) (Year)	As of ____/____ (Month) (Year)
# of Claims Paid:	______________	______________	______________	______________

What percentage of your student athletes have primary medical insurance coverage? ____________

I understand that the premium is fully earned upon policy inception.

Mail both pages of this application to:

Or fax it to: (630) 665-7294. Questions? Call us at (800) 745-2409.