Student Catastrophic 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

Number of High Schools

Number of Junior High Schools

CATASTROPHIC ACCIDENT MEDICAL PLAN DESIRED:

All enrolled students of the school, all activities, all sports.

		Includes Interscholastic Tackle Football
		Excludes Interscholastic Tackle Football

	All interscholastic athletes, cheerleading, and participants of non-sport extracurricular activities of the School
		Includes Interscholastic Tackle Football
		Excludes Interscholastic Tackle Football

	All interscholastic athletes, band members, cheerleaders, majorettes, participants of intramural sports, gym classes and non-sport extracurricular activities of the school
		Includes Interscholastic Tackle Football
		Excludes Interscholastic Tackle Football

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.
Email Address:

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