Associated Insurance Plans International, Inc. The Worldwide Student Insurance Specialist with The Personal Touch!
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    Online Request for Student Health Insurance    

Personal Information:

* Required Fields

First Name   Last Name
Title:   Name of Institution
Address 2:
City   State   Zip
Phone:   Fax:
- - - -
E-mail: *

I Am Interested In Receiving A Proposal For:

Student Health Insurance:   Intercollegiate Athletic Insurance:
Short Term or "In Between" Protection:   Dental Insurance for:
International Student Coverage:
  Not covered Mandatory Voluntary Waiver


Student Health Insurance

In Order To Present You With The Lowest Possible Cost, Please Provide The Following Information:
Number of Students:   What % are Commuters? %
Do you have an infirmary? Yes No Number of Beds Dispensary
Do you employ nurses? If so, what is their availability?
office hours full time

Current Coverage is: Mandatory Voluntary
  Year before Last Last Year Current Year
Dates (mm/yy) to to to
No. of Insured Students:
Cost Per Student:
Total Premiums:
Claims Paid:

What agency handles your present plan?
If our plan proves interesting, what agency would you prefer for local service?

Do you wish our proposal to be:
Mandatory Voluntary Waiver           Other
Shall We:
Mail the proposal to you? Have one of our representatives deliver the plan? Contact agent shown above?
Date:   Deadline: