Insurance Waiver Form
Please read the information below regarding student accident insurance.  If you have adequate insurance coverage already in place, please sign the form at the bottom of the page indicating that you are waiving this additional coverage.
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Student Accident Insurance Information
Dear Parents/Guardians:

The school district does not provide any type of health or accident insurance for injuries incurred by your child at school.

REASONS TO PURCHASE THIS COVERAGE:
Deductibles and copays in your health plan. Many health plans have increased the amount of out-of-pocket expenses.
No insurance.

This plan will provide benefits for medical expenses incurred because of an accident. If you have other insurance, our benefits will be applied to your deductible or co-pay.

If you have no other insurance this will become your primary accident plan.

To purchase coverage:
Print names, addresses and other information clearly on the enrollment form.
Make check or money order payable to STUDENT ASSURANCE SERVICES INC.
Print Student’s name on the face of the check.
Detach and retain the summary of coverage, and return the enrollment form to school within 10 days. Coverage does not become effective until the premium is received by the school.
All questions regarding the coverage should be directed to Student Assurance Services, Inc., at (651) 439-7098, or toll free 800-328-2739.
What is your student's first and last name? *
What grade is your student in this year? *
Please choose from the following: *
Parents/Guardians:  Please type your name in all capital letters as your electronic signature indicating that you have adequate insurance protection for your son/daughter while practicing or participating in interscholastic activities. *
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