Please complete this form to the best of your knowledge. Completing this form will provide Trustway T.E.A.M. Services the necessary information to provide a quote for your college / university. Additional Information may be necessary.
School Information
College / University:
Address:
Address:
Contact Person Name:
Phone:
Email:
2009-10 Information
Insurance Company:
Agent:
Out of Pocket Expenses:
(Amount Paid by University to Meet Deductible)
Claims:
Benefit Period:
Maximum Benefit:
2008-09 Information
Insurance Company:
Agent:
Out of Pocket Expenses:
(Amount Paid by University to Meet Deductible)
Claims:
Benefit Period:
Maximum Benefit:
2007-08 Information
Insurance Company:
Agent:
Out of Pocket Expenses:
(Amount Paid by University to Meet Deductible)
Claims:
Benefit Period:
Maximum Benefit:
2006-07 Information
Insurance Company:
Agent:
Out of Pocket Expenses:
(Amount Paid by University to Meet Deductible)
Claims:
Benefit Period:
Maximum Benefit:
Thank you for your interest in Trustway T.E.A.M. Services
