Application For Student 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: Conrad Weiser Area School District
Please choose the school your child attends.
School:

School Sponsored Student Accident Insurance Plan

Zurich American Insurance Company Schaumburg, Illinois

A. SCHOOLTIME
ONLY PLAN

B. 24 HOUR 'ROUND
THE CLOCK' PLAN

STUDENTS
GRADES K-12
$30 per year
Add this coverage
$113 per year
Add this coverage

Student Life Insurance

Transamerica Premier Life Insurance Company, Cedar Rapids, Iowa
$30 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 DOB
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's 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.

By typing my name below, I acknowledge that I am electronically signing this application for insurance. All statements made on this application are true and complete to the best of my knowledge and belief.

Click here to read our privacy policy.

Your Name
Your Mother's Maiden Name
I acknowledge I have read the Insurance Disclosure and Privacy Policy outlined above.

FRAUD WARNING

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person 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. 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, at Zurich American Insurance Company?s sole discretion, 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.




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