Student Accident Insurance Enrollment Form
Academic Year 2017 - 2018

Plan 1508/1540


Underwritten by:
Ameritas Life Insurance Corp.
Lincoln, Nebraska


Voluntary Plan Sports and non Sports Coverage


Click here to view the Insurance Brochure

Click here to view a hard copy of the Enrollment Form

If you choose to enroll by mail, download the enrollment form above,
complete the form and mail it with your payment to:
Student Assurance Services, Inc., P.O. Box 196, Stillwater, MN 55082-0196.


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


       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 the later of: the Master Policy Effective Date 08-01-2017; or 12:01 AM 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 AM following the date the premium payment is received by the Plan Administrator. Interscholastic sports coverage will expire on the last day of the authorized season of the current school year. School-Time and Full-Time coverages end the first day of school next year. No refunds, except as provided in Master Policy.

The Basic Full-Time ($99) and Basic School-Time ($16) plans do not include coverage for interscholastic sports grades 7-12. Sports Coverage for grades 7-12 is available by selecting Full-Time w/Interscholastic Sports ($174) or School-Time w/Interscholastic Sports ($91). These plans will provide coverage for all sports except football grades 9-12. Football coverage ($250) must be purchased separately.

PREMIUM RATE
 ANNUAL

Basic Full-Time Coverage (PK-12) no interscholastic sports for Grades 7-12
  $99.00

Full Time Coverage (7-12) with all interscholastic sports
except Football for Grades 9-12
 $174.00

Basic School Time Coverage (PK-12) no interscholastic sports for Grades 7-12
  $16.00

School Time Coverage (7-12) with all interscholastic sports
except Football for Grades 9-12
  $91.00

GAA-2203 Ed.11-16 C-1508/1540


      
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.




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