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Enrollment Form for Club/Intramural Sports Catastrophic Insurance Underwritten by Mutual of Omaha Insurance Company; 3300 Mutual of Omaha Plaza; Omaha, NE 68175

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Enrollment Form for Club/Intramural Sports Catastrophic Insurance Underwritten by Mutual of Omaha Insurance Company; 3300 Mutual of Omaha Plaza; Omaha, NE 68175 Enrollment Form for Club/Intramural Sports Catastrophic Insurance Underwritten by Mutual of Omaha Insurance Company; 3300 Mutual of Omaha Plaza; Omaha, NE 68175 1. General Information Name of Institution Full Legal Name Address Street City State Zip Contracting Official Name Title Phone Fax E-mail Address 2. Premium (See back side of form for sports list and risk categories) A. Club Sports Complete the General Information under Section 1. Fill in the total number of Club Sport participants (female and male). Please be sure to look through all sections and categories as all Club sports listed in the census section will be included in the quote. Total Club Sport Premium $ B. Intramural Sports Complete the General Information under Section 1. Fill in the total number of Intramural Sports participants (female and male). Please be sure to look through all sections and categories as all Intramural sports listed in the census section will be included in the quote. Total Intramural Sport Premium $ Grand Total Club and Intramural Sport Premium $ (There is a nonrefundable minimum premium of $750.00) Make premium check payable to Relation and mail payment along with this completed form to one of the following offices: Overland Park: Salt Lake City: P.O. Box 25936 2180 South, 1300 East, Suite 520 Overland Park, KS 66225 Salt Lake City, UT 84106 1-800-955-1991, ext. 5614 1-800-955-1991, ext. 2627 Attn: Janice Briggs Attn: Carol Malouf 3. Term of Coverage It is understood that the effective date of coverage under this program will be August 1, or the date this form and the premium are received and accepted by the Company, whichever is later. Coverage expires one year from the effective date. By Date Signature of Contracting Official Licensed Agent’s Signature License Number Date MUGC9568_IN1 See Brochure for Additional Information 2018 – NAIA Club/Intramural Cat CLUB/INTRAMURAL SPORTS AND RISK CATEGORIES (Please indicate the # of Participants per sport within each category) Name of Institution Low Risk Category Medium Risk Category # of # of # of Club # of Club Sports Intramural Sports Intramural Sport Sport Sport Sport Participants Participants Participants Participants Aerobics Baseball Archery Cheerleading Badminton Climbing Wall Band Cycling Basketball Dodgeball Billiards Equestrian Bowling Figure Skating Canoe/Kayak Football (Flag or Touch) Cricket Log Rolling Cross Country Running Marathon Cross Country Skiing Paintball Curling Quidditch Dance Scuba Disc Golf Swimming E-games Track & Field Fencing Triathlon Fishing Water Polo Golf Water Skiing Handball Racquetball Riflery Rowing/Crew Sailing Soccer Softball Squash Student Managers Student Trainers Synchronized Swimming Tennis (Table or Court) Ultimate Frisbee Volleyball Walking Weightlifting Wiffle Ball Yoga Zumba TOTAL TOTAL Relation is an independent licensed insurance agency and is authorized to sell this student accident insurance on behalf of Mutual of Omaha Insurance Company. CLUB/INTRAMURAL SPORTS AND RISK CATEGORIES (Please indicate the # of Participants per sport within each category) Name of Institution High Risk Category Very High Risk Category # of Club # of # of Club # of Sport Sports Intramural Sport Sports Intramural Participants Sport Participants Sport Participants Participants Climbing Boxing Diving Football (Tackle) Field Hockey Gymnastics Judo/Karate/Martial Arts Ice Hockey Lacrosse Polo Outdoor Adventure Rodeo Rafting Rugby Roller Hockey Skiing Snowboarding Surfing Wakeboarding Wrestling TOTAL TOTAL Relation is an independent licensed insurance agency and is authorized to sell this student accident insurance on behalf of Mutual of Omaha Insurance Company. .
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