Enrollment For Student Accident Insurance

Directions: Please make your selections below for each coverage you would like to purchase for this applicant. Then, complete the applicant's information.

School Information

School District: Anderson County School District 01
Please choose the school your child attends.

24 Hour Accident Insurance

Guarantee Trust Life Insurance Company, Glenview, Illinois
$120 Total cost per year per student
Add this coverage

Dental Accident Insurance

Catlin Insurance Company, Inc., Houston, TX
$20 Total cost per year per student
Add this coverage

Student's Information

Student's First Name
Student's Last Name
Student's Middle Initial
Student's Gender
Student's Age
Student's Date of Birth
Student's Grade
Student's Address

Mailing Address (if different from above):
Click if same as Students Address

Parent/Guardian Information

Parent/Guardian's First Name
Parent/Guardian's Last Name
Parent's Middle Initial
Parent's Gender
Parent/Guardian's Relationship to Insured
Parent/Guardian's Home Phone
Parent/Guardian's Cell Phone
Parent/Guardian's Work Phone
Parent's Email Address
Mailing Address (if different from students):
Click if same as Students Address
Parent/Guardian's Address
Parent/Guardian's Apt.
Parent/Guardian's City
Parent/Guardian's State
Parent/Guardian's Zip

Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance fraud and subject to criminal and civil penalties.

Electronic Signature and Insurance Disclosure

I hereby enroll the above named student.

I acknowledge that my name printed below represents my electronic signature, which is legally binding and enforceable and is the legal equivalent of my handwritten signature. All statements made on this application are true and complete to the best of my knowledge and belief.

Your Name
Your Mother's Maiden Name
I acknowledge I have read the Insurance Disclosure and Privacy Policy outlined above.
Click here to read our privacy policy.

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