| Leonard Insurance Services | |||||
| IMPORTANT! | |||||
| Claims Experience Must Be Provided To Be Eligible For A Proposal | |||||
| For Academic Year | Premium Paid | Paid Claims | |||
| (Current & 3 Prior Years) | |||||
| Current | $ | $ | |||
| One Year Prior | $ | $ | |||
| Two Years Prior | $ | $ | |||
| Three Years Prior | $ | $ | |||
| Additional Claim Information Can Be Very Helpful In Providing The Lowest Possible Quote | |||||
| Intercollegiate Sports | Number of Participants | Intercollegiate Sports | Number of Participants | ||
| Male | Female | Male | Female | ||
| Football - Fall Only | Golf | ||||
| Football - Spring Only | Swimming | ||||
| Ice Hockey | Diving | ||||
| Soccer | Water Ballet | ||||
| Lacrosse | Fencing | ||||
| Rugby | Rowing | ||||
| Skiing | Crew | ||||
| Judo | Field Hockey | ||||
| Karate | Sailing | ||||
| Wrestling | Archery | ||||
| Boxing | Riflery | ||||
| Baseball | Bowling | ||||
| Softball | Volleyball | ||||
| Basketball | Badminton | ||||
| Gymnastics | Equestrian | ||||
| Track & Field | Flag Football | ||||
| Squash | Cheerleaders | ||||
| Racquet Ball | Drill Team | ||||
| Water Polo | Band | ||||
| Cross Country | (Other) | ||||
| Tennis | |||||
| Reminder: If your current Student Insurance (Non-Athletic) Plan does not cover Intramural or Club Sports, please include the date (same as above) for a quotation. | |||||
| SPORT CAMP QUOTES ARE ALSO AVAILABLE | |||||
| 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 2 | ||||