Covid-19 Update: RPS Bollinger Specialty Group remains fully operational during this crisis. Our Customer Support Staff, Claims Department and New Business Team are here to answer questions. Connect with RPS Bollinger Specialty Group through your usual channels or through the "Contact Us" link options on this site. We wish you and your families good health during this difficult time, and a safe transition back to your workplaces and schools in the near future.

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: Pasco County Public Schools
Please choose the school your child attends.
School:

School Sponsored Student Accident Insurance Plan

Mutual of Omaha Insurance Company, Omaha, Nebraska
Low Option Rates  High Option Rates
     LOW OPTION RATES
A. AT SCHOOL
ONLY PLAN 		B. 24 HOUR
STUDENTS
GRADES K-12 		$21.40 per year
Add this coverage 		$86.65 per year
Add this coverage
C. 24 HOUR SUMMER ONLY
$22.45 per year
Add this coverage
and/or
D. HIGH SCHOOL FOOTBALL
$147.65 per year
Add this coverage
and/or
E. SPRING HIGH SCHOOL FOOTBALL
$58.85 per year
Add this coverage
and
F. EXTENDED DENTAL
$9.65 per year
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
Apt.
City
State
Zip


Mailing Address (if different from above):
Click if same as Students Address
Street
Apt.
City
State
Zip

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



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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