5071 WEST H AVENUE | KALAMAZOO, MI 49009 | 269.381.6630 Home Products Forms About Us Contact Us } 1st Agency: K-12 Coverage Request for Quote BLANKET STUDENT AND/OR ATHLETIC ACCIDENT COVERAGE SCHOOL INFORMATION Name of School District * Street Address * City * State * Zip Code * INFORMATION PROVIDED BY Contact Name * Phone Number * Email Address * COVERAGE INFORMATION Current Plan Maximum Deductible PLAN INFORMATION Mandatory for all Students and Athletes Mandatory for all Athletes Only Mandatory for all Students Only (No Sports) CLAIM HISTORY: Please list for the last four school years. SCHOOL INFORMATION 2019-2020 2018-2019 2017-2018 2016-2017 Premium Paid Claims Paid High Schools Text High Schools Middle Schools Elementary Schools Total Enrollment (K-12) Enrollment Number of Schools QUOTE REQUEST Date Quote Needed Please enter any other pertinent information you would like to add here Please indicate which plan(s) you desire quoted Mandatory for all Students and Athletes Mandatory for all Athletes Only Mandatory for all Students Only (No Sports) Other (ie: Deductible, etc.) COVERED PARTICIPANTS Please check covered participants for High School below. MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE Baseball Football (Spring) Rowing Crew Track & Field (Outdoor) Basketball Golf Soccer Volleyball Cheerleaders Gymnastics Softball Wrestling Cross Country Ice Hockey Student Managers / Trainers Football (Fall) Lacrosse Swimming Other Sports (Please list Male and Female Participants) Please check covered participants for Middle School below. MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE Baseball Football (Spring) Rowing Crew Track & Field (Outdoor) Basketball Golf Soccer Volleyball Cheerleaders Gymnastics Softball Wrestling Cross Country Ice Hockey Student Managers / Trainers Football (Fall) Lacrosse Swimming OTHER SPORTS (Please list Male and Female Participants): CONTACT US Address 5071 WEST H AVENUE | KALAMAZOO, MI 49009 Call Now 269.381.6630 Mail 1stAgency@1stAgency.com EXPLORE OUR SITE Home About Us Contact Us © Gallagher 1999 - 2021. Legal Information Terms of Use Privacy Policy Compensation Disclosure