Catastrophic Accident Enrollment Form

Name of School or School District:

Address:

City/State/Zip:

Contact Name:

Contact Title:

Benefit:

Number of Students (PreK-12):

All Pre-Kindergarten through 12th grade enrolled students. Coverage includes intramural sports participants. Coverage excludes interscholastic sports participants, cheerleaders, and dance team members.

Number of Athletes (PreK-8):

All Pre-Kindergarten through 8th grade: interscholastic athletes, cheerleaders, band members, majorettes, student coaches and student managers/student trainers only.

Number of Athletes (Senior High):

All Senior High: interscholastic athletes, cheerleaders, band members, majorettes, student coaches and student managers/student trainers only. Coverage is during the school's summer and/or winter breaks.

Phone Number:

Fax Number:

E-mail Address:

Coverage will become effective on the Date this Enrollment Form is signed or on the date this request and the premium are received by Dissinger Reed, LLC, whichever is later.

Premium:

Policy Fee:

$25.00

Total Amount Due:

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CATASTROPHIC ACCIDENT INSURANCE ENROLLMENT FORM: 2025 - 2026 POLICY YEAR

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