Student Accident Insurance Enrollment Form
Academic Year 2019-2020

Plan 2520


Underwritten by:
Ameritas Life Insurance Corp.
Lincoln, Nebraska


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.


       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): 
* Home Address: 
* City: 
* State: 
* Zip: 
* Parent Name: 
* Parent Phone Number: 
* Parent EMail: 

Student Information
* First Name: 
* Last Name: 
  Middle Name: 
* Date of Birth: 
 (mm/dd/yyyy)
  Social Security: 
 (ex. 123-45-6789)
* Grade: 
* Status: 



PREMIUM RATES

 ANNUAL
Full-Time Coverage (PK-12) no interscholastic sports (Grades 7-12)  $89.00
School Time Coverage (PK-12) no interscholastic sports (Grades 7-12)  $14.00


ADDITIONAL COVERAGE
   



All students must attend the same school or district.



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.


GAA-2203 Ed.11-16 E-2520


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.

Acknowledgement
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:
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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