Student Accident Insurance Enrollment Form
Academic Year 2017 - 2018

Plan C-1745


Underwritten by:
Ameritas Life Insurance Corp.
Lincoln, Nebraska



Voluntary Plan Sports and non Sports Coverage


Click here to view the Insurance Brochure


       If you choose to enroll online, payment is required by credit card.
       To enroll online complete the form shown below.

       There will be a $5.00 transaction fee charged for online enrollment.


       Fields marked with an asterisk (*) must be filled in.


* School Name (or District): 
* First Name: 
* Last Name: 
  Middle Name: 
* Date of Birth:   (mm/dd/yyyy)
  Social Security:   (ex. 123-45-6789)
if you do not have a SSN enter 999-99-9999
* Address: 
* City: 
* State: 
* Zip: 
* Phone Number: 
* EMail: 
* Status: 


Coverage becomes effective on the later of: the Master Policy effective date 08-01-2017; or 12:01 A.M. following the date the envelope containing the enrollment form and premium payment is postmarked by the U.S. Postal Service; or for online enrollment 12:01 A.M. following the date the proper premium is received by the Plan Administrator. All coverage expires on the Master Policy expiration date 07-31-2018. No refunds, except as provided in the Master Policy.

The Basic full-time ($105) and school-time ($25) plans do not include coverage for interscholastic activities (UIL). UIL activities coverage is available by selecting full-time with interscholastic UIL activities ($195) or school-time with interscholastic UIL activities ($115). These plans will provide coverage for all UIL interscholastic activities except varsity football, which is covered by selecting varsity football coverage ($325). Students who purchase varsity football coverage will be covered for fall, spring and summer football. Students who purchase either full-time with UIL/Sports ($195) or school-time with UIL/Sports ($115) will be covered for spring and summer football if they did not purchase fall football coverage ($325) during the fall season.

PREMIUM RATE
 ANNUAL
Basic School Time Coverage
No UIL/Sports Activities
  $25.00
Basic Full Time Coverage (24 hour)
No UIL/Sports Activities
 $105.00
School Time Coverage
Includes All UIL/Sports Activities except Varsity Football
 $115.00
Full Time Coverage (24 hour)
Includes All UIL/Sports Activities except Varsity Football
 $195.00

GAA-2200 Ed.11-16 C-1745TX


      
ADDITIONAL COVERAGE
   
   


Electronic Signature

BY CHECKING THE BOXES AND ENTERING MY NAME BELOW I AM INDICATING MY INTENT TO ELECTRONICALLY SIGN THIS APPLICATION AND WARRANT THAT ALL OF THE INFORMATION I HAVE PROVIDED IS TRUE, COMPLETE, AND ACCURATE.



Please type your name in the space below to electronically sign your application:
Name: 
(Parent or guardian if under 18 years of age)
Date:   mm/dd/yyyy

TO BEGIN ENROLLMENT IN THIS INSURANCE PLAN, PLEASE CLICK ON THE "NEXT" BUTTON.




If you are experiencing any problems with this page please contact the webmaster.