Fillable Student Medical Underwriting Questionnaire36-10806

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Student Medical Underwriting Questionnaire36-10806

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STUDENT MEDICAL UNDERWRITING QUESTIONNAIRE
Name of School:
Street Address:
City:
State:
Zip Code:
1.
Number of Enrolled students
Full-Time, Domestic Undergraduate Students:
International Students:
Graduate Students:
Part-Time Students:
2.
Please provide the rates charged per student, per spouse and per child for the 4 most recent policy years:
Rate Per
Student
Spouse
Child
Current School Year
Current Year Minus 1
Current Year Minus 2
Current Year Minus 3
3. Please provide the number of students, spouses and children covered under the student medical plan for
the four (4) most recent policy years:
Number Enrolled
Students
Spouses
Children
Current School Year
Current Year Minus 1
Current Year Minus 2
Current Year Minus 3
4.
Name of Preferred Provider Organization used:
5.
List the five (5) medical providers most often used by students:
1.
2.
3.
4.
5.
6.
Does the school have an on-campus health services center?
Yes
No
If yes, please provide a list of services available at the health center:
7. In order to provide a quote for the School’s Student Health Insurance Plan, please also provide the
following:
•
Copies of the plan brochures for the four (4) most recent policy years.
•
Copies of the claim reports for the four (4) most recent policy years. The claim reports
should show claim payments by benefit type for each year reported.
Student Medical Underwriting Questionnaire
Page 1 of 2
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
Print Application
Clear Application
ACKNOWLEDGEMENTS AND SIGNATURES
a.
Fraud Warning It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
b.
Applicant’s Acknowledgement I, the Applicant, declare, to the best of my knowledge and belief, that all
statements and answers in this application are true and complete. I understand and agree that (a) this application
will form part of any policy issued, (b) no information given to or acquired by any representative of Philadelphia
Indemnity Insurance Company will bind it, unless it is in writing on this application, (c) no waiver or modification will
bind the Company unless it is in writing and is signed by an executive office of Philadelphia Indemnity Insurance
Company and (d) only those persons eligible under the terms of an issued policy will be insured.
Signature: ______________________________________
Title:
Date:
Agent Name:
Agency:
Address:
City:
State:
Zip:
Email:
Phone:
Fax:
Please return form to:
The Allen J. Flood Companies, 2 Madison Avenue, Larchmont, NY 10538
info@ajfusa.com ● Phone: 1-800-734-9326
Student Medical Underwriting Questionnaire
Page 2 of 2
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
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Student Medical Underwriting Questionnaire36-10806

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Completed 2 July 2020

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