Student Accident Insurance Enrollment Form
Academic Year 2021 - 2022
Ameritas Life Insurance Corp.
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.
Coverage becomes effective the later of: the Master Policy Effective Date 08-01-2021; 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.
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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