Fillable Student Accident Insurance is Now More Important Than (Irvine Unified School District)

Fill Online, Printable, Fillable, Blank Student Accident Insurance is Now More Important Than (Irvine Unified School District) Form

Use Fill to complete blank online IRVINE UNIFIED SCHOOL DISTRICT pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Student Accident Insurance is Now More Important Than (Irvine Unified School District)

On average this form takes 9 minutes to complete

The Student Accident Insurance is Now More Important Than (Irvine Unified School District) form is 4 pages long and contains:

  • 2 signatures
  • 15 check-boxes
  • 21 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Irvine Unified School District forms online.

BROWSE IRVINE UNIFIED SCHOOL DISTRICT FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
2019-2020
my
ers
I
stevens
I
toohe
y
640
Despite your best efforts
to protect them, children
get hurt and out-of-pocket
expenses for medical care
can be signicant.
•
Is your child already covered?
•
Does your plan have large deductibles
and co-insurance?
•
Do you want to be able to see the doctor
that YOU choose?
Student Accident
Insurance is Now
More Important
Than Ever!
School Year
Arranged and Administered by:
Our Plans Can Help!
Affordable Rates Call (800) 827-4695 With Questions
Determine the Plan(s) you want to purchase
Plans showing include enhanced Concussion Benefit - See next page for details
Student Accident & Sickness Plan
Our Best Coverage!
Students (Grades P-12) may enroll in this plan. Covers Injuries sustained and Sickness
commencing anywhere in the world, 24 hours a day, while your student is insured under
this School Year’s plan (including interscholastic sports, except interscholastic high
school tackle football). Repatriation and Medical Evacuation benefits are included. This
plan does not cover routine or preventative care.
Benefits are payable according to the “Description of Benefits” up to $50,000 per Covered
Sickness and $200,000 per Covered Accident.
Coverage begins at 11:59 p.m. on the day Myers-Stevens & Toohey & Co., Inc. (herein
called “The Company”) receives the completed enrollment form and premium. Coverage
ends at 11:59 p.m. on the last day of the month for which payment has been made.
Coverage may be continued for up to 12 calendar months, or through Sept. 30, 2020,
whichever comes first, provided the required payments are made.
There is a $50 deductible per covered Accident or covered Sickness.
NOTE – Participation in commercial camps or clinics may be covered under this plan.
Interscholastic Tackle Football
Accident Plans
Students (grades 9-12) may enroll in these plans. Covers Injuries caused by covered
accidents occurring:
• While practicing or playing in interscholastic high school tackle football
activities which are School-sponsored and directly supervised, including
spring practice and summer conditioning, weight training and passing league
• While traveling for football in a School Vehicle or traveling directly and without
interruption between School and off-campus site for such activities provided
travel is arranged by and is at the direction of the School
Coverage begins at 11:59 p.m. on the day the Company receives the completed
enrollment form and premium. Coverage ends at 11:59 p.m. on the closing date of
regular classes for the 2019-2020 School Year.
NOTE – Participation in commercial camps or clinics is not covered under these plans.
See “Full=Time 24/7” plans. Practice or playing of football must be conducted under the
regulations and jurisdiction of the applicable sports governing body
Benefit Levels: High Mid Low
Rates per School Year: $339 $295 $235
Full-Time 24/7 Accident Plans
Students (grades P-12 and school employees) may enroll in these plans. Covers
Injuries caused by covered Accidents occurring 24 hours a day, anywhere in the world
and while participating in all interscholastic sports except interscholastic high school
tackle football.
Coverage begins at 11:59 p.m. on the day the Company receives the completed
enrollment form and premium. Coverage ends at 12:01 a.m. on the date School begins
regularly scheduled classes for the 2020-2021 School Year.
NOTE – Participation in commercial camps or clinics may be covered under this plan.
Benefit Levels: High Mid Low
Rates per School Year: $328 $276 $225
School-Time Accident Plans
Students (grades P-12) may enroll in these plans. Covers Injuries caused by covered
Accidents occurring:
• On School premises during the hours and on days when the School’s regular
classes are in session, including one hour immediately before and one hour
immediately after regular classes, while continuously on the School premises
• While participating in or attending School-sponsored and directly supervised
School Activities including interscholastic athletic activities and non-contact
spring football (except interscholastic high school tackle football)
• While traveling directly and without interruption to or from residence and
School for regular attendance; or School and off campus site to participate in
School-sponsored and directly supervised School Activities, provided travel is
arranged by and is at the direction of the School; and while traveling in School
Vehicles at any time.
Coverage begins at 11:59 p.m. on the day the Company receives the completed
enrollment form and premium. Coverage ends at 11:59 p.m. on the closing date
of regular classes for the 2019-2020 School Year.
NOTE – Participation in commercial camps or clinics is not covered under these plans. See
“Full-Time 24/7” plans.
Benefit Levels: High Mid Low
Rates per School Year: $79 $68 $53
Dental Accident Plan ($75,000 Maximum)
Students (grades P-12) may enroll in these plans. Covers Injuries to teeth caused by
covered Accidents occurring 24 hours a day, anywhere in the world, including participation
in all sports and all forms of transportation.
Benefits are payable at 100% of the Usual, Customary and Reasonable charges
for Treatment of Injured teeth, including repair or replacement of existing caps or
crowns. We do not pay for damage to or loss of dentures or bridges or damage to existing
orthodontic equipment.
The coverage provides a “Benefit Period” of Accident dental benefits for up to one year
from the date of first Treatment. The benefit period for an Injury may be extended each
year, provided that: coverage is renewed prior to October 1, the student remains enrolled
in grades P-12, and written notice is received by the Company at the time of Injury that
further Treatment will be deferred to a later date.
Coverage begins at 11:59 p.m. on the day the Company receives the completed
enrollment form and premium. Coverage ends at 12:01 a.m. on the date School begins
regularly scheduled classes for the 2020-2021 School Year.
$16.00 purchased separately
$12.00 when added to any plan(s) purchased
Pharmacy SmartCard
Available to students, their families and school staff through our partnership with CastiaRx
(formerly known as NPS), the SmartCard offers savings of up to 95% of prescription drug costs
and is accepted at over 63,000 pharmacies nationwide.
In addition, the program can provide “Instant Alerts” to potential medication interactions to better
protect your family along with unique “Proof of Savings” reports mailed directly to you every six
months.
After your payment has been processed, NPS will send you your ID card. Present your card
each time you or a family member needs a prescription filled to receive your savings. For more
detailed information, go to www.pti-nps.com or call 800-546-5677.
The SmartCard is not an insurance product and is not insured by Ace American Insurance
Company.
$36.00 for entire family, for one full year!
1st payment: $208.00
(Covers remainder of month in which you enroll and 1 additional month)
Subsequent Payments: $169.00 a month, billed every 2 months
™
Choose Your Own Doctor and Hospital
Benefits for Accidental Death, Dismemberment, Loss of Sight, Paralysis and Psychiatric/Psychological Counseling
(Applies to all plans except the Dental Accident Plan and Pharmacy
SmartCard)
In addition to medical benefits, if, within 365 days from the date of Accident
covered by the policy, bodily Injuries result in any of the following losses, we
will pay the benefit set opposite such loss. Only one such benefit (the largest)
will be paid for all such losses due to any one Accident.
• Accidental Death $10,000
• Single dismemberment or entire loss of sight in one eye $25,000
• Double dismemberment or entire loss of sight in both eyes, or paraplegia or hemiplegia or quadriplegia $50,000
Counseling - In addition to the AD&D benefits, we will pay 100% of the Usual, Customary and Reasonable costs
of psychiatric/psychological counseling needed after covered dismemberment, loss of sight or paralysis up to $ 5,000
Determine the benefit level that best fits your needs
If your child has no other insurance, we recommend the Student Accident & Sickness Plan or the High Option plans.
Description of Benefits
(Applies to all plans except the Dental Accident Plan and Pharmacy SmartCard)
We will pay benefits only for Covered Injuries sustained or Covered Sickness commencing while insured under this School Year’s plan. Benefits payable will be based on the Usual,
Customary and Reasonable Charges incurred for covered medical and dental services, as defined by the Policy, subject to exclusions, requirements and limitations. We do not pay for a
service or supply unless it is Medically Necessary and listed in the Description of Benefits below. Applicable benefits mandated by the state of residence will be included in the covered
expenses. You may take your child to any provider you choose; however, seeking Treatment through a First Health contracted provider may reduce your out-of-pocket costs.
To find participating First Health medical providers nearest you, call 800-226-5116 or log on to www.myfirsthealth.com.
Covered Benet Levels Low Option Mid Option High Option Student Accident & Sickness Plan
Plan Name MAXIMUMS PER ACCIDENT
$50,000 Maximum per Sickness
$200,000 Maximum per Accident
Tackle Football Accident Plan $25,000 $50,000 $75,000
Full-Time 24/7 Accident Plan $50,000 $100,000 $150,000
School-Time Accident Plan $25,000 $50,000 $75,000
Deductible - per condition
$200 $100 $50 $50
Covered Expenses BENEFIT MAXIMUMS BENEFIT MAXIMUMS
Hospital Room & Board - Semi Private Room Rate 80% 85% 90% 80%
Inpatient Hospital Miscellaneous Charges 80% to $2,000/Day 85% to $2,500/Day 90% to $3,000/Day 80% to $4,000/Day
Intensive Care Unit
80% 85% 90% 80%
Hospital Emergency Room
(room & supplies) incurred within 72 hours of an Injury
100% 100%
Emergency Room Physician Charges 100% 100%
Outpatient Surgical
(room & supplies) 80% to $2,500 85% to $3,000 90% to $5,000 80% to $4,000
Physician Non-Surgical Treatment & Exam
(excluding Physical Therapy) Including consultation (when
referred by attending Physician)
80% 85% 90% 80%
Surgeon Services 80% 85% 90% 80%
Assistant Surgeon Services 80% 85% 90% 80%
Anesthesiologist Services 80% 85% 90% 80%
Physiotherapy
(includes related ofce visits)
when prescribed by a Physician
80% to $500 85% to $750 90% to $1,000 80% to $2,000
X-Ray Examinations (including reading) 80% to $500 85% to $750 90% to $1,000 80%
Diagnostic Imaging
MRI, Cat Scan 80% 85% 90% 80%
Ambulance
(from site of an emergency directly to hospital) 100% 100%
Laboratory Procedures, Registered Nurse Services,
and Rehabilitative Braces
80% 85% 90% 80%
Durable Medical Equipment 80% to $400 85% to $750 90% to $1,000 80%
Out-Patient Prescription Drugs
(for Injuries only) 80% 85% 90% 80%
Dental Services (including dental x-rays)
for Treatment due to a covered Accident
80% 85% 90% 80%
Eyeglass Replacement
(for replacement of broken eyeglass
frames or lenses resulting from a covered Accident requiring
medical Treatment)
$500 $500 $500 80%
Medical Evacuation & Repatriation $0 $0 $0 100% to $10,000
ENHANCED CONCUSSION BENEFIT: When a student is diagnosed with a concussion as a result of an injury received while participating in a Covered Activity, and as a
result is prohibited from participation in interscholastic sports under the School’s formal concussion protocol, benets for the treatment of that injury will be paid at 100% of the
Usual, Customary and Reasonable charges with no deductible, subject to all other terms and conditions of the plan.
X
2019 - 2020 Enrollment Form
Complete all information (please print)
and return to Myers-Stevens & Toohey & Co., Inc.
Student Name First Middle Last
- -
Student Birthdate
Mailing Address Apt.#
City State Zip Code
- -
Parent Daytime Phone Number
Parent E-mail Address
District Name
School Name Grade
Available for your convenience is the option to have your bi-monthly payments
automatically charged to your credit card.
By initialing here ______________, I hereby authorize Myers-Stevens & Toohey to
charge the above credit card $338, plus a 3% processing fee, on the 5th of the month
that my payment is due. This authorization will remain in effect for the 2019/2020 school
year until I notify Myers-Stevens & Toohey in writing prior to the next payment date.
Auto-Charge Option
Method of Payment
Note: $25.00 service charge for Returned Checks and declined Credit Cards
Check/Money Order
(Make payable to: Myers-Stevens & Toohey & Co., Inc.)
or
Mastercard
®
or Visa
®
Important: If paying by credit card, complete below. Charge will appear as
“MYERS-STEVENS & TOOHEY 800-827-4695 CA” on your statement.
- - -
Card Number
3 digit
control #
EXP. DATE
MO. YR.
Signature of Cardholder
Amount
$
Print Name of Cardholder Zip Code
640.AZ/CA/NV
Easy Enrollment
Student Accident & Sickness
1st Payment $208.00
You will be billed $338.00 every 2 months thereafter.
Coverage cannot exceed 12 calendar months or run past Sept. 30, 2020.
Our BEST Plan
Our Accident Plans
PREMIUMS CANNOT BE REFUNDED OR CONVERTED
1
2
3
2
1
Instructions
Thank you for enrolling your child!
To avoid any delay in coverage, please follow these 3 easy steps below:
Select the plan(s) you wish to purchase below:
• The Student Accident & Sickness Plan will provide our highest level of
coverage.
• Our Accident Plans may be purchased on an individual basis or combined with
additional coverage (for example, Full-Time Accident + Dental).
Complete and detach the enrollment form on the right side or you may enroll
online (see below). Please note, we are unable to accept enrollments over the phone.
Purchase and Return
CLICK HERE to enroll online for IMMEDIATE processing!
We accept VISA and MasterCard.
If online enrollment is not available, you may either:
Fax the completed Enrollment Form to (949) 348-2630. You must pay by
credit or debit card by completing the payment area on this page. We cannot
accept Checks or Money Orders by fax.
Email
a scanned image of the completed Enrollment Form to
apply@myers-stevens.com. You must pay by credit card by completing the
payment area on this page. We cannot accept Checks or Money Orders by
email.
Mail both sides of the completed Enrollment Form in the enclosed envelope.
You may pay by credit card by completing the payment area on the right side
enclose a check or Money Order made payable to Myers-Stevens & Toohey
& Co., Inc.
PLEASE DO NOT SEND CASH
I authorize Myers-Stevens & Toohey & Co. Inc. to deduct the premium
payment, plus a 3% processing fee, from my credit card. If enrolling in the
Student Accident & Sickness Plan, I am authorizing the initial premium
payment and understand that I will be invoiced every 2 months for the
subsequent payments.
(One-Time Payment For Entire School Year)
PLANS: High Option Mid Option Low Option
Tackle Football Only
$339.00
$295.00
$235.00
Full-Time (24/7)
$328.00
$276.00
$225.00
School-Time
$79.00
$68.00
$53.00
Dental Accident
$16.00
Purchased Separately
$12.00
When added to any plan(s) purchased
Pharmacy Smart-
Card
$36.00
Total Amount Due
$
Print Parent or Guardian Name
I have enrolled for the coverage checked above as provided by the Family Insurance Trust
where applicable. I understand premiums cannot be refunded or converted.
WARNING: Any person who knowingly and with intent to defraud any insurance company
or other persons, les a 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, subject to criminal prosecution and/or
civil penalties.
X
__________________________________________________
Parent or Guardian Signature Date
6
*
+
click to sign
signature
click to edit
click to sign
signature
click to edit
Frequently Asked Questions...
If I have other insurance, why do I need this
coverage?
Our plans can expand your choice of providers for your child
and can help cover deductibles, co-pays and other out-of-
pocket expenses.
I’m in a hurry! What is the quickest way to enroll?
Click HERE to enroll online and you will receive immediate
proof of coverage as soon as your payment is processed.
If my child has no other insurance, what’s my best buy?
Unless you need coverage for high school tackle football, the
Student Accident & Sickness Plan is our broadest, best option.
Next best is the Full-Time 24/7 Accident Plan with “High
Option” benefits.
Can I take my child to any doctor or hospital?
YES! However, your out-of-pocket costs could be less by
using a First Health contracted provider. To find participating
doctors/hospitals nearest you, call
800-226-5116 or log on to www.myfirsthealth.com
Are accident-only rates paid every month?
NO! Accident-only rates are one-time charges for the entire
School Year.
Can interscholastic high school tackle football
be covered?
YES! But only under the Interscholastic Tackle Football Plan.
“High Option” benefits are recommended.
Do the Interscholastic Tackle Football or School-Time
plans cover camps and clinics sponsored and organized
by groups other than my child’s school?
NO! However, such camps and clinics may be covered
under our Full-Time 24/7 or Student Accident & Sickness
plans. Call us for guidance!
Still need help or have questions?
Go to www.myers-stevens.com or
call us for prompt, personalized
assistance at (800) 827-4695.
How To File A Claim
1. Report School-related Injuries to the School office:
• Within 60 days if you reside in California
• Within 72 hours if you reside in Arizona or
Nevada
To find a First Health provider nearest you, call
800-226-5116 or log on to www.myfirsthealth.com.
2. Obtain a claim form from the School or the
Company. Claim forms must be filed with the
Company within 90 days after the date of first
Treatment.
3. At the same time, please file a claim with your
other family sickness and/or Accident carrier.
4. Follow ALL claim form instructions, attach all
itemized bills and send to:
This information is a brief description of the
important features of this insurance plan. It is
not an insurance contract. Insurance benefits
are underwritten by ACE American Insurance
Company. Coverage may not be available in all
states or certain terms may be different where
required by state law. Chubb NA is the U.S.-
based operating division of the Chubb Group of
Companies, headed by Chubb Ltd. (NYSE:CB)
Insurance products and services are provided
by Chubb Insurance underwriting companies
and not by the parent company itself.
2018 Best Rated A++ (Superior)
(A.M. Best rating ranges from A++ to D)
This rating is an indication of the company’s
financial strength and ability to meet
obligations to its insureds.
The Insurance
Company
(Does not apply to the SmartCard)
Myers-Stevens & Toohey & Co., Inc.
26101 Marguerite Parkway
Mission Viejo, CA 92692-3203
800-827-4695 • Fax 949-348-2630
claims@myers-stevens.com
CA License #0425842
myers
I
stevens
I
toohey
Benefits are not payable for any of the following or loss that results from them:
1. Damage to or loss of dentures or bridges or damage to existing orthodontic equipment.
2. War or any act of war, declared or undeclared.
3. Participation in a riot or civil disorder; fighting or brawling, except in self-defense; commission of or attempt to commit a felony or violating or attempting to
violate any duly enacted law.
4. Suicide, attempted suicide or intentionally self-inflicted Injury while sane or insane.
5. Injury or Sickness contributed to by the use of alcohol or drugs unless taken in the dosage and for the purpose prescribed by the Covered Person’s Physician.
6. Practice or play in interscholastic high school tackle football (unless separate football coverage is purchased), intercollegiate sports, semi-professional sports,
or professional sports. (Does not apply to the Dental Accident Plan.)
7. Injury or Sickness covered by Worker’s Compensation or Employer’s Liability Laws, or by any coverage provided or required by law including, but not limited
to group, group type, and individual automobile “No Fault” coverage (excluding School Vehicle coverage).
8. Treatment, services or supplies provided by the School’s infirmary or its employees, or Physicians who work for the School, or by any member of the Covered
Person’s immediate family; or for which no charge is normally made.
9. Mental or nervous disorders (except as specifically provided by the Policy).
10. Treatment of Sickness, ailment, or infections (except pyogenic infections or bacterial infections which result from the accidental ingestion of contaminated
substances). (Does not apply to the Sickness-Only Coverage under the Student Accident & Sickness Plan.)
11. The diagnosis and Treatment of non-malignant warts, moles and lesions, acne or allergies, including allergy testing.
12. Injury sustained as a result of riding in or on, entering or alighting from, a two or three-wheeled motor vehicle. (Does not apply to the Dental Accident Plan.)
13. Treatment of osteomyelitis, pathological fractures and hernia. (Does not apply to the Sickness-Only Coverage under the Student Accident & Sickness Plan.)
14. Detached retina (unless directly caused by an Injury). (Does not apply to the Sickness-Only Coverage under the Student Accident & Sickness Plan.)
15. Any expenses related to the Treatment of tonsils, adenoids, epilepsy, seizure disorder or congenital weakness; or expenses for Treatment of congenital
anomalies and conditions arising or resulting directly there from.
16. Supplies, except as otherwise provided in the Policy.
This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit Us from providing insurance, including but not
limited to, the payment of claims.
Requirements and Limitations
Aggravations of injuries which did not occur while insured under this plan are paid up to $500 maximum benefit per policy term. Injuries sustained as a result of riding
in or on, entering or alighting from or being struck by a Motor Vehicle are limited to a $25,000 maximum benefit. Some Motor Vehicle injuries are not covered - see
exclusions above for details. School-time and high school tackle football injuries must be reported to the School within 60 days of the date of Injury if you reside in
California or 72 hours if you reside in Arizona or Nevada. The first Physician’s visit must be within 120 days after the Accident occurs. This insurance does not apply to
the extent that trade or economic sanctions or regulations prohibit us from providing insurance, including but not limited to, the payment of claims. A claim form must
be filed with Myers-Stevens & Toohey & Co., Inc. within 90 days after the date of loss. The School-Time, Tackle Football and Full-Time (24/7) plans pay for covered
expenses incurred within up to 104 weeks from the date of injury. The Student Accident & Sickness and Dental Accident plans pay for covered expenses incurred within
up to 52 weeks from the date of first treatment, however, should the Injury sustained under the Student Accident & Sickness plan require the removal of surgical pins,
continued Treatment for serious burns, or Treatment of a non-union or mal-union fracture, the benefit period will be extended to 104 weeks. Each covered condition
may be subject to a deductible - see plan details.
Facility of Payment
Whenever payments that should have been made under the Policy are made by any other policy, the Company reserves the right to pay over to any plan making such
other payments, any amounts the Company determines are warranted in order to satisfy the intent of this provision. The amounts paid are considered benefits paid
under the Policy and, to the extent of such payments, the Company shall be fully discharged from liability under the Policy. In no event will the Company pay more than
the benefits payable under the Policy for all policies providing the same or similar benefits issued to the Policyholder and underwritten by the Company.
Definitions
An Accident is defined as a sudden, unexpected and unintended incident. Covered Accident means an Accident that results in Injury or loss covered by this Policy.
An Injury is defined as Accidental bodily harm sustained by the Covered Person that results directly from an Accident (independently of all other causes) and occurs
while coverage under the Policy is in force. Medically Necessary is defined as the services or supplies provided by a Hospital, Physician, or other provider that are
required to identify or treat an Injury or Sickness and which, as determined by the Company, are: (1) consistent with the symptoms or diagnosis and Treatment of the
Injury or Sickness; (2) appropriate with regard to standards of good medical practice; (3) not solely for the convenience of the Insured Person; (4) the most appropriate
supply or level of service which can be safely provided. When applied to the care of an Inpatient, it further means that the Insured Person’s medical symptoms or
condition requires that the services cannot be safely provided as an Outpatient. Sickness is defined as illness or disease contracted by and causing loss to the Insured
Person whose Sickness is the basis of claim. Any complications or any condition arising out of a Sickness for which the Insured Person is being treated or has received
Treatment will be considered as part of the original Sickness. School Activities means any activity that is sponsored and under the direct, immediate supervision of
the School that: (a) the School requires the Insured Person to attend; or (b) is under the sole control and supervision of School authorities. It does not include an activity
related to athletics or cheerleading that is under joint sponsorship or supervision arrangement with any non-School group.
Excess Provision:
In order to keep premiums as affordable as possible, these plans pay benefits on a non-duplicating basis. This means, if a person is covered by one or more of these
plans and by any other valid insurance or health agreement, any amount payable or provided by the other coverages will be subtracted from the covered expenses and
we will pay benefits based on the remaining amount. (In Arizona: Does not apply to the Sickness-Only coverage under the Student Accident & Sickness Plan.)
IMPORTANT NOTICE:
This Plan provides short-term limited duration sickness benefits. It does not constitute comprehensive health insurance coverage (often referred to as “major
medical coverage”) and does not satisfy a person’s individual obligation to secure the requirement of minimum essential coverage under the Affordable Care Act (ACA). For more information about
the ACA, please refer to www.HealthCare.gov.
Premiums Cannot be Refunded or Converted
For a brochure in Spanish, or for assistance in Spanish, please call 800-827-4695
Para un folleto en Español, o para asistencia en Español, por favor llame a 800-827-4695
Call (800) 827-4695 With Questions
AZ/CA/NV PND 640 03/19
Exclusions
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Student Accident Insurance is Now More Important Than (Irvine Unified School District)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document