Risk Management Information
Certified Athletic Trainer (s) on staff? Yes No
Team Physician: On Staff On Retainer Other: _____________________________________________
Require pre-participation physical examination? Yes No
Type of institution? Public Private
What percentage of your athletes have primary medical coverage? _____ %
Does your school have any special billing and/or payment arrangements with hospitals, physicians, or other providers? Yes No
If yes, please explain: __________________________________________________________________________________________
A
gent Information
A
gent: _______________________________________________________ Agency: _____________________________________________
Address: _____________________________________________________ City/State/Zip: __________________________________________
Email: _______________________________________________________ Phone: _______________________________________________
Intercollegiate Sports Accident Insurance Application 011521 Page 2 of 2 aliverisk.com
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