(Detach Here)
Student Accident Insurance 2020/2021 Enrollment Form
After selecting the school-approved insurance plan that’s best for you:
❏ Detach and complete the enrollment form
❏ Enclose a check or money order
❏ Do not send cash
❏ Return enrollment form and check or money order to:
Relation Insurance Services
700 SE Central Parkway
Stuart, FL 34994
Exclusions and limitations
Beneits will not be paid for injuries caused by:
(1) suicide, intentionally self-inlicted injury, or any attempt thereat while
sane or insane;
(2) commission or attempt to commit a felony or an assault; or commission
of or active participation in a riot or insurrection;
(3) declared or undeclared war or act of war;
(4) services or treatment provided by persons who do not normally charge
for services, unless there is a legal obligation to pay;
(5) light in, boarding or alighting from an aircraft except as a fare-paying passenger
on a regularly scheduled commercial or charter airline;
(6) travel in or on any on-road or of-road vehicle that does not require motor
vehicle licensing;
(7) bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding;
(8) an accident if the covered person is the operator of a motor vehicle and
does not possess a valid motor vehicle operator’s license, unless the
covered person holds a valid learners permit and the covered person
is receiving instruction from a driver’s education instructor;
(9) services or treatment rendered by any person who is employed
or retained by the policyholder or living in the covered person’s
household; a parent, sibling, spouse or child either of the covered
person or the covered person’s spouse; the covered person;
(10) cosmetic surgery, except for reconstructive surgery needed as the result
of a covered injury;
(11) injuries compensable under workers’ compensation law or any similar law;
(12) sickness, disease, bodily or mental illness, bacterial or viral infection or
medical or surgical treatment thereof, except for any bacterial infection resulting
from an accidental external cut or wound, or accidental ingestion
of contaminated food;
(13) the covered person being legally intoxicated as determined according
to the laws of the jurisdiction in which the covered accident occurred or
voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless
prescribed or taken under the direction of a physician and taken in accordance
with the prescribed dosage;
(14) any hospital stay or days of a hospital stay that are not appropriate treatment
for the condition and locality;
(15) participation or practice for non-school sponsored skiing, ice hockey, lacrosse,
soccer or tackle football (applicable to school time coverage only);
(16) taking part in senior high school interscholastic football, soccer, hockey
or lacrosse, including travel to and from games and practice, unless these
coverages have been elected.
School name: _______________________________________________________________________________ District name: ___________________________________________________ Grade/dept: ________________
Person to be insured: ___________________________________________________________
Address: _____________________________________________________________________________________
City: _________________________________________State: _________ ZIP: _______________
Phone:______________________________________________________________________________
Date of Birth: __________________________________________________________________________________
Social Security #: ___________________________________________________________________
Parent Signature: __________________________________________________________________
Policy Number (company use only) _____________________________________________________
Date: ___________________________ Amount enclosed: _________________________ (Do not send cash)
Please include check or money order payable to: QBE Insurance Corporation
There is no obligation to purchase this insurance plan.
Do you want this insurance? ❏ Yes ❏ No
Coverage chosen: Basic Double Triple
School Time Coverage ❏ $8 ❏ $16 ❏ $24
24Hour Coverage ❏ $50 ❏ $99 ❏ $149
Full season football ❏ $50 ❏ $99 ❏ $149
Spring football only ❏ $19 ❏ $38 ❏ $58
Soccer, hockey or lacrosse ❏ $19 ❏ $38 ❏ $58
Beneits for football or soccer, hockey and lacrosse coverage can be purchased in addition to the School Time
or 24Hour plans.
