Student Accident Medical Insurance Enrollment Form

GENERAL INFORMATION

Name School(s):

School Official Name:

Mailing Address:

City

State ZIP

Phone:

( ) - ext.

Fax:

( ) -

Email Address:

School Year Starts:

/ /

School Year Ends:

/ /

Anticipated Enrollment:

	Total Enrollment	Number of Athletes
Grades PreK - 6 or 8
Grade 6-8 OR
7-9
Grades 9-12 OR
10-12
Boarding Students
Summer School

BASIC STUDENT ACCIDENT MEDICAL PLAN DESIRED:

All Students School Time:
*If you have interscholastic sports
complete census below

	All Students - All Sports*
	All Students - No Sports

	Includes Interscholastic Tackle Football*
	Excludes Interscholastic Tackle Football*

Sports Coverage:
*Complete census below

	All Students - Includes Interscholastic Tackle Football*
	All Students - Excludes Interscholastic Tackle Football*

Voluntary Coverage :

	School Time
	24-Hour
	Dental
	Life
	Interscholastic Tackle Football*

* SPORTS COVERAGE: Complete the census below. Use your current year numbers.

School Sponsored and Supervised Sport/Activity	Number of Senior	Number of Junior
Football	---------------------------
Varsity		-----------------------------
Jr. Varsity		------------------------------
Freshman		------------------------------
Band
Baseball
Basketball
Cheerleaders
Cross Country
Drill Team
Flag Corps
Golf
Pep Squad
Soccer
Softball
Swimming
Tennis
Track
Volleyball
Wrestling
Drama
Journalism
Math
Music
Other:

PREVIOUS COVERAGE INFORMATION
It is important you complete as much of the following so we can provide the best programs possible for your school and your students.

Coverage Year (ie: 2005-06) - Please provide current information from the last 3 years.
Year
Premium	$	$	$
Claims History	As of	As of	As of
Dollar Amount of Claims Paid	$	$	$
Claims Over $5,000 (number / amount)
Name of Insurance Company
Plan Design (i.e. Maximum, Benefit Period)

Local Agency Name:
Local Agent Name:
Agent Address:

Phone Number:	( ) - ext.
Fax Number:	( ) -
Email Address:

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