Group Enrollment Form

2020-2021 NORTH AMERICAN DIVISION OF SEVENTH-DAY ADVENTIST

K-12 ACCIDENT INSURANCE COVERAGE REQUEST FORM

Enrollment

Eligibility:

Class 1 - All enrolled students (grades PK-12, includes enrolled and registered early childhood infants to school age), including the graduating class trip, religious services or instructions and all interscholastic student athletes excluding senior high football are covered under the Policyholder program for whom premium has been paid.

Class 2 – All enrolled boarding students (grades PK-12) excluding senior high football are covered under the Policyholder program for whom premium has been paid.

Base Plan Options:

Please make selections below indicating the Desired Plan of Coverage.

Class 1
Corridor Deductible
1a: Preschool & Kindergarten
*1b: Day Students Grade 1-8
1c: Students Grade 9-12
$0.00
$6.56
$13.33
$41.21
$100.00
$4.51
$10.25
$30.96
$0.00
$9.84
$18.86
$54.94
Class 2
Corridor Deductible
Boarding Students
$0.00
$128.74
$100.00
$94.71
$0.00
$217.30
*If a school has 9th & 10th grade students and no 11th & 12th grade students, use rates for Grades 1-8 for the 9th & 10th grade students.

CAT Plan Options:

Please make one of the boxes below indicating the Desired Plan of Coverage.

CAT Plan Options
 
$2.30
$3.30
$
×
= $
$
×
= $
$
×
= $
$
×
= $
$
×
= $
$

(The Premium Due is fully earned and nonrefundable on the effective date of coverage)
Underwritten by: Mutual of Omaha Insurance Company; 3300 Mutual of Omaha Plaza; Omaha, NE68175

Mail completed enrollment form to the following address:

Relation Insurance Services
P.O. Box 25936
Overland Park, KS 66225
1-800-955-1991, ext. 5614
Attn: Janice Briggs

Term of Coverage
It is understood that the effective date of coverage under this program will be August 1, or the date this form and the premium are received and accepted by the Company, whichever is later. Coverage for this term will expire on August 1.
By
Date

 

Adventist Risk Management
Mutual of Omaha
Relation Education Solutions
M88800 0420
Policy Form T5MP