Student Accident Insurance Enrollment Form
Academic Year 2024 - 2025

Plan 1745

Underwritten by:
Ameritas Life Insurance Corp.
Lincoln, Nebraska


Voluntary Plan Sports and non Sports Coverage

Click here to view the Insurance Brochure


       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: 
 (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: 
* Status: 



PREMIUM RATES

 ANNUAL
Basic School Time Coverage
No UIL/Sports Activities		  $30.00
Basic Full Time Coverage (24 hour)
No UIL/Sports Activities		 $117.00
School Time Coverage
Includes All UIL/Sports Activities except Varsity Football		 $120.00
Full Time Coverage (24 hour)
Includes All UIL/Sports Activities except Varsity Football		 $207.00


All students must attend the same school or district.



GAA-2200 Ed.6-20 J-1745TX


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.



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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