Student Accident Insurance Application

Name of School *

Contact Name (First/Last) *

Address *

City

State

Zip Code

Email Address

Phone Number

Fax Number

Effective Date of Coverage

Coverage Plan Desired

Full Excess
Primary

Does the school now have this type of coverage?

Yes No

If yes, with whom?

Educational Institution

K12
Private/Prep School
College/University
Study Abroad

Academic Year or Summer Program?

Academic Year
Summer Program

Number of Residents

Overnight Residents

Day Students

Please provide the premium and loss information for the past four years in the space below

Agent/Broker Name

Agent/Broker Address

Agent/Broker Telephone Number

Policyholder Signature

Policyholder Title

Date

Please list all sports affiliated with this school:

STUDENT ACCIDENT INSURANCE APPLICATION