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: Hazlet Board of Education
Please choose the school your child attends.

24 Hour Accident Insurance

Zurich American Insurance Company Schaumburg, Illinois
$92 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 includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

The Enrollee hereby enrolls for Accident Insurance and declares that:

All information provided in this enrollment form and any attachments hereto is true and correct to the best of my knowledge and belief. The undersigned understands that all information provided in this enrollment form and any attachments hereto is material to Zurich American Insurance Company's decision to provide this insurance, and that insurance will be provided in reliance upon the truth of such information.

It is hereby understood and agreed that:
1. this insurance is provided by Zurich American Insurance Company in consideration of payment of the required premium; and
2. the insurance under the policy begins no sooner than the date the Company or its Agent approves the Enrollment Form.

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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