Student Accident Insurance Enrollment Form
Academic Year 2019-2020
Ameritas Life Insurance Corp.
Voluntary Student Insurance 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.
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 Master Policy.
The Full-Time ($89) and School-Time ($14) plans do not include coverage for interscholastic sports grades 7-12 in Public Schools and grades 9-12 in Parochial Schools.
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.
I understand by applying for coverage I am agreeing to the eligibility requirements of enrollment as outlined in the brochure and important provisions above.
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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