Group Enrollment Form -- K-12 Accident Medical -- Risk Strategies

2023-2024 NORTH AMERICAN DIVISION OF SEVENTH-DAY ADVENTIST
K-12 ACCIDENT INSURANCE COVERAGE REQUEST FORM

Name of School or School Conference *

Street Address *

City *

State *

Zip *

Phone

Fax

Email *

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
Full Excess	$0.00	$6.10	$12.40	$38.33
Full Excess	$100.00	$4.19	$9.53	$28.79
$500 Primary Excess	$0.00	$9.15	$17.54	$51.09

Class 2	Corridor Deductible	Boarding Students
Full Excess	$0.00	$119.73
Full Excess	$100.00	$88.08
$500 Primary Excess	$0.00	$202.09

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

Medical Only	$2.14
CAT Cash	$3.07

Number of Students	Rate per Student	Total
Base Class 1a Preschool & Kindergarten	$0.00	$0.00
Base Class 1b Day Students Grade 1-8	$0.00	$0.00
Base Class 1c Students Grade 9-12	$0.00	$0.00
Base Class 2	$0.00	$0.00
CAT	$0.00	$0.00
*The Premium Due is fully earned and nonrefundable on the effective date of coverage	Total Premium Due:	$0.00


Underwritten by: Mutual of Omaha Insurance Company 3300 Mutual of Omaha Plaza Omaha, NE 68175		For questions regarding enrollment or plan coverage, please contact: Stephanie Williams Account Executive direct (913) 815-1300 stephanie.williams@ahpcare.com Debbie McFarlane Account Manager direct (913) 392-9414 deborah.mcfarlane@ahpcare.com

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.

Signature of Contracting Official *

Date *

2023-2024 NORTH AMERICAN DIVISION OF SEVENTH-DAY ADVENTIST K-12 ACCIDENT INSURANCE COVERAGE REQUEST FORM

2023-2024 NORTH AMERICAN DIVISION OF SEVENTH-DAY ADVENTIST
K-12 ACCIDENT INSURANCE COVERAGE REQUEST FORM