Student Accident Insurance Enrollment Form
Academic Year 2023 - 2024

Plan 1513

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.        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):	--Select Your School-- Alpena Public Schools Bark River-Harris Schools Cadillac Public Schools Farmington Public Schools Forest Area Community Schools Grand Ledge Public Schools Jonesville Community Schools Morenci Area Schools Reading Community Schools Royal Oak Public Schools Troy School District
*	Home Address:
*	City:
*	State:	--Select a State-- Outside the US or Canada Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Labrador Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
*	Zip:
*	Parent Name:
*	Parent Phone Number:
*	Parent EMail:	(please use only lower case letters)
Student Information
*	First Name:
*	Last Name:
	Middle Name:
*	Date of Birth:	(mm/dd/yyyy)
	Social Security:	(ex. 123-45-6789)
*	Grade:	- Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12
*	Status:	PK-12
PREMIUM RATES   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
ADDITIONAL COVERAGE     $250.00 Football Coverage Grades 9-12     $9.00 Extended Dental Coverage Grades PK-12
Add Another Student All students must attend the same school or district.

Coverage becomes effective the later of: the Master Policy Effective Date 08-01-2023; 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.