2024 Student Accident Quote Request Form

If you have any questions or concerns, please contact PSBA Insurance Marketing Manager Torie Tezik at torie.tezik@psba.org. For information about Student Accident Insurance and more, please visit PSBAinsurance.com.

Request for Proposal

Current Plan

Mandatory/Blanket Coverage

Claims and Premium History Reports

Please provide plan summaries or contracts and premium vs. claim reports, if available, in order to provide a thorough underwriting review to provide more precise pricing.

A minimum of three years of historical data is required, but four to five years is preferred.

Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag files to this area to upload. You can upload up to 3 files.

Catastrophic Coverage

Please complete the class section(s) you are interested in receiving insurance quotes for.

Class I: All enrolled students of the school/school district, including all sports and activities

Class II: All interscholastic sports, including football and cheerleading

Class III: All interscholastic sports, including football, band, cheerleading, majorettes, intramural sports, gym classes, and non-sport extracurricular activities