Fillable APPLICATION for: Student Accident Insurance ENROLLMENT (All Risks, Ltd)

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APPLICATION for: Student Accident Insurance ENROLLMENT (All Risks, Ltd)

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APPLICATION for: Student Accident Insurance
Name of
School or District: ______________________________________________________________________________
Address: _____________________________________________________ County: ________________________________
City: ___________________________________________________ State: _________________ Zip: _________________
Telephone Number: _______________________________ Fax Number: __________________________________________
Contact Name: ___________________________________ Insured Email Address: __________________________________
ENROLLMENT
Estimated Enrollment: _______________ Number of Students: Pre K – K: _______ 1 – 8: _______ 9 – 12 _______
Number of Junior High Schools: _______
Number of Senior High Schools: _______
Number of Football Players: _________
Senior High: _______ Junior High: _______
Number of Athletes (excluding Football): __________ Senior High: _______ Junior High: _______
COVERAGE REQUEST
Mandatory
All Students, All Sports, Including Football All Students, All Sports, Excluding Football
All Students Excluding All Sports and Football Football Athletes Only Athletics Only
Include coverage for:
Before/After School Care Volunteers Overnight Trips Other: ______________
Voluntary
Spring Football
School Time – Includes Sports/Excludes Football
24-Hour – Includes Sports/Excludes Football
Fall Football
24-Hour – Excludes all Sports
Dental
Catastrophic Medical
All Students Athletes Only Including Football Athletes Only Excluding Football
Other: __________________
PREMIUM AND CLAIMS DATA Date Claims Valued (MM/DD/YYYY): ___________________
Policy Year
(Beg – End)
Premium
Claims
Benefit Changes from Previous Year
$
$
None OR
List Changes:
$
$
None OR
List Changes:
$
$
None OR
List Changes:
$
None OR
List Changes:
AGENT INFORMATION
Agent: ______________________________________ Agency: _________________________________________
Address: _____________________________________________________________________________________
Email: ______________________________________ Phone: __________________________________________
*Please provide a copy of the current policy for each requested coverage.
St
udent Accident Application 011521 Page 1 of 1 aliverisk.com
$
Alive Risk is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a subsidiary of
Ryan Specialty Group, LLC (RSG). Alive Risk works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the public. Some products may
only be available in certain states, and some products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC (License #
0G97516). ©2021 Ryan Specialty Group, LLC
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APPLICATION for: Student Accident Insurance ENROLLMENT (All Risks, Ltd)

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Completed 20 January 2021

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