Student Accident Insurance Enrollment Form
Academic Year 2019 - 2020
Ameritas Life Insurance Corp.
Voluntary Plan Sports and non Sports Coverage
Click here to view the Insurance Brochure
Coverage becomes effective on the later of: the Master Policy effective date 08-01-2019; 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 07-31-2020. 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.
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:
TO BEGIN ENROLLMENT IN THIS INSURANCE PLAN, PLEASE CLICK ON THE "NEXT" BUTTON.
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