Student Accident Insurance Enrollment Form
Academic Year 2025 - 2026

Plan 1513

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):	--Select Your School-- Ada-Borup Public Schools Alexandria Public Schools Bagley Public Schools Belgrade-Brooten-Elrosa Public Schs Bemidji Public Schools Bertha-Hewitt Schools Blackduck Public Schools Blooming Prairie Public Schools Blue Earth Schools Braham Public Schools Brainerd Public Schools ISD 181 Buffalo - Hanover - Montrose Schools Buffalo Lake-Hector Schools Canby Public Schools Central Minnesota Christian School Clinton/Graceville/Beardsley Schools Comfrey Public Schools Dawson-Boyd Public Schools Delano Public Schools Detroit Lakes Public Schools Dilworth/Glyndon/Felton Schools Eden Prairie Schools Edgerton Public Schools Elk River Public Schools Ely Public Schools Fergus Falls Public Schools Fertile-Beltrami Schools Fillmore Central School District Floodwood Public Schools Fosston Public School Frazee-Vergas Public School Glencoe-Silver Lake Public Schools Granada-Huntley-East Chain Schools Grand Rapids ISD 318 Hibbing Public Schools Hills-Beaver Creek Public Schools Hinckley/Finlayson Public Schools Houston Public Schools Hutchinson Public School Lac Qui Parle Valley Public Schools Lake Crystal/Wellcome Memorial School District Lakeview Public Schools Lancaster Public Schools LeRoy-Ostrander Schools Luverne Public Schools MACCRAY Public Schools Mankato Public Schools Maple Lake Public Schools Marshall County CSD Marshall Public Schools Martin County West Schools Menahga Public Schools Minnesota Valley Lutheran School Minnetonka Public Schools Monticello Public School District Mora Public Schools Mountain Lake Public Schools New Ulm Catholic School New Ulm Public Schools New York Mills Schools Ortonville Public Schools Osseo Public Schools Owatonna Public Schools Pequot Lakes Public Schools Perham Dent Public Schools Pierz Public Schools Pine River-Backus Public Schools Plainview-Elgin-Millville Comm Sch Red Rock Central Public Schools Red Wing Public Schools Redwood Area Schools Royalton Public Schools Rushford-Peterson Schools Sauk Centre Public Schools South St. Paul Public Schools Spring Lake Park Schools Springfield Public Schools St Charles Public Schools St Cloud Public Schools St Louis County Public Schools St Marys School Bird Island St Marys School Sleepy Eye St Michael-Albertville Schools St Paul's Lutheran School - New Ulm Stephen/Argyle Public Schools Swanville School District Tracy Area Schools Triton Public Schools Underwood Public Schools Wabasha-Kellogg Public Schools Wabasso Public Schools Waconia Public Schools Walker-Hackensack-Akeley Schools Waseca Public Schools Wheaton Area Schools Windom Public Schools Worthington Public Schools
*	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 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 Grades 9-12   $91.00
ADDITIONAL COVERAGE     $250.00  Football Coverage (9-12)     $9.00  Extended Dental Coverage (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; 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 expire on the selected expiration date of the annual term policy. 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.