Leonard Insurance Services
INTERCOLLEGIATE  SPORTS  REQUEST  FOR  PROPOSAL
Name of School:
Address:
City:				State:		Zip:
Information provided by:
		Name				Title
Phone:  (          )				Fax:  (         )
Please provide the following information for a proposal
		Two Years Prior		One Year Prior		Current Year
1.	Maximum Medical Coverage	$		$		$
2.	Accidental Death & Dismemberment Benefit	$		$		$
3.	Deductible Amount	$		$		$
4.	Excess or Primary
5.	Benefit Period (1, 2, or 3 Years)
6.	Expanded Medical Benefit (Yes or No)
7.	Heart Circulatory Coverage (Yes or No)
8.	Re-Injury / Re-Aggravation (Yes or No)
9.	Pre-Existing Conditions Covered (Yes or No)
10.	HMO / PPO Supplement Benefit (Yes or No)
11.	Insurance Carrier
12.	Coinsurance (Yes* or No)
	*If yes, 70%, 80%, or 90%
Quote Current Year Plan (Yes or No)
Quote Current Year Plan With the Following Changes:
Does Your Current Student Insurance Plan Cover Intramural or Club Sports?
If Not, Do You Want These Included?
Please Return This Completed Form To:		Leonard Insurance Services
	(Front and Back)	4244 Mount Pleasant Street NW Suite 200
		North Canton, Ohio 44720
		(800) 451-1904     Fax (330) 498-9946
		Clark D. Swisher				Page 1