Inscribase en Internet Nuestros productos de Seguros para estudiantes protegen a miles de nioos de los golpes y moretones de la infancia.

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1 Enroll Online Our Student Insurance products protect thousands of kids from the bumps and bruises of growing up. K12 Accident and Health Plans available through your school: Injury and Sickness (available in AZ,FL,NC,OK only) At-School Accident Only 24-Hour Accident Only Extended ental Football How to Enroll Enrolling online is easy and should take only a few minutes. Go to and click the "Enroll Now" button. 1. Start by telling us the name of the school district and state where your child attends school. 2. We'll request each student's name and grade level. 3. You'll see the available plans and their rates. Select your coverage and continue to the next step. 4. We'll request information about you, like your name and address. 5. Next, you'll enter information about the child or children to be covered. 6. Enter your credit card or echeck payment information. 7. Finally, print out a copy of the confirmation for your records. For further details of the coverage including costs, benefits, exclusions, any reductions or limitations and the terms under which the policy may be continued in force, please refer to Student is able to purchase the coverage only if his/her school district is a policyholder with the insurance company (05111_K12) Inscribase en Internet Nuestros productos de Seguros para estudiantes protegen a miles de nioos de los golpes y moretones de la infancia. Los Planes de salud y accidente para estudiantes en grados K-12 disponibles a traves de su escuela son: Lesion yenfermedad (disponibles unicamente en AZ, FL, NC YOK) Accidente en la escuela unicamente Accidente con cobertura las 24 horas unicamente Plan dental extendido Futbol americano Como inscribirse Inscribirse en Internet es facil y no deberia tomarle mas que unos minutos. Vaya a y haga clic en el boton "Inscribirse ahora". 1. Para empezar, dfganos el nombre del distrito escolar y el estado donde esta la escuela a la que asiste su hijo. 2. Le pediremos el nombre y el grado de cada estudiante. 3. Vera los planes disponibles y sus cargos. Seleccione su cobertura y vaya al siguiente paso. 4. Le pediremos informacion sobre usted, como par ejemplo su nombre y direccion de correo electronico. 5. Acontinuacion, introducira la informacion sobre el{los) hijo{s) para los que solicita cobertura. 6. Introduzca la informacion de pago con su tarjeta de credito 0 un cheque electronico. 7. Por ultimo, imprima una copia de la confirmacion para sus registros. irijase awww.studentinsurance-kk.com para mas detalles sobre la cobertura, incluidos los costos, beneficios, exclusiones, toda reduccion 0 limitacion y los terminos en virtud de los que la poliza puede continuar estando vigente. EI estudiante puede adquirir la cobertura unicamente si el distrito escolar tiene una poliza con la compania de seguros.

2 Protect your child with Student Accident Insurance School is not aspectator sport. From hopping and skipping to blocking and tackling, our commitment to protecting kids starts as early as kindergarten. That's why we're here! Online Enrollment-Secured Accident &Health Plans Coverage can be purchased any time throughout the year. Remember to visit our website for faster enrollment. Checks, money orders, or credit cards accepted. O NOT SEN CASH Serviced by: K&K Insurance Group, Inc. Phone: ; ""'7111-,.". "J1 ~ ~,~,~~. 2015~201. SchoolYear. "'.~.:- ;r. ) ~

3 Y...~...~.t"'/,s ~ (;L/.t"'N' ~ Insurance Agency Sen'in8 Ib.., CommulJity Siltc J9()J Student Accident Insurance Enrollment Form A. General Information Narne of U,",'''V'HI School Mailing [~U\.I..L" ""'. City: State: Zip: Contact B. Voluntary Plans Estimated annual school enrollment (total number ofstudents): =---:-. Grades (mark one): [J PK-12 [J Elementary School [J Middle School [J High School Effective ate: ate offirst day ofclass for following school c. Mandatory Plans (Coverage selected by school/district) At-School Including Athletics & Activities 'Ai.~School Excluding Athletics & Activities Product Option Grade Total # ofinsured Rate Premium Athletic & Activities Field Trip School Band ROTC ---:... Other (Please Specify) Other (Please Specify) Other (Please Specify). Notes I understand that the insurance company, in determining whether to provide insurance coverage, will rely on the information contained in this for and all other information being submitted. I hereby warrant, represent and confmn that, to the best ofmy knowledge, all information provided is complete, true and correct. I further acknowledge that I have reviewed all information provided with this enrollment form and understand the exclusions that apply, as well as the activities and operations for which coverage is not provided. Signature of Official Authorized to Contract for SchooVistrict ate Signed Printed Name Title Agent Signature ate Signed Agent Printed Name Agent Number

4 .1.,.1("'("'41"'/"5 '[~ru,~ Insurance Agency S~rv;IJg Your COmn'lul,il.\' Si,fCC JfJ03 Student Accident Insurance Supply Requisition Form Namemv.~...v. Supplies IMPORTANT FOR SUPPLIES: An initial supply of student enrollment forms will be shipped to the district office or one central location. Requested brochure type: Mail Back Bring Back Web Only Enrollment Shipping Ship Supplies to: istrict Office ate supplies..vvuvu. o you want your supplies separated by campus? No Please indicate quantity msupplies. ~. ~... Yes Please indicate quantity msupplies below. o you want apdf file of the brochure ed to you to post on your school website? Yes No Please provide Campus Locations Please provide a list of campus locations so all locations will be listed on the website for online enrollment You may attach alisting of all campuses or fill in below. If supplies are to be separated by campus, indicate number of forms needed next to each campus location. campus I I... Slate:. -'Zip: Spanish Fonns rurenllwl: TIUe:. I I campus..u".~~ Title:. campus I I I I v",.. state: Zip:_.. mle:~

5 EngOsh Forms City: state: Zip:_ Number 01 Title: NU~berOf Englls Forms City:_... _--- Slate:,lip: Title: Campus Name:_ City: state: Zip:.. TItle: City:... state: Zip: Num~of Spanis rms Title:. Engsh Forms City:... state: Zip: Title: City: --...~ City: Number 01 state: Zip: TItle: state: State: Title: Title: Zip: Zip: c:::=j City: state: Zip: TItle: 11i62 (03l12_K12) WWH'.reerlUl1l1r.COIII

6 Y~~,e"'/"5 ~ (;an" ~ Insurance Agency St'tving Yo", C OII1»fUIJity Sillt: /9().J Student Accident Insurance Supply Requisition Form Name of Supplies IMPORTANT FOR SUPPLIES: An initial supply of student enrollment forms will be shipped to the district office or one central location. Requested brochure type: a Mail Back a Bring Back a Web Only Enrollment Shipping Ship Supplies to: a istrict Office City: ""...,......"., ate supplies.vv vv... o you want your supplies separated by campus? a No Please indicate quantity of supplies a Yes Please indicate quantity of supplies below. o you want apdf file of the brochure ed to you to post on your school website? a Yes Please provide ano Campus Locations Please provide alist of campus locations so all locations will be listed on the website for online enrollment. You may attach alisting of all campuses or fill in below. If supplies are to be separated by campus, indicate number of forms needed next to each campus location. campus campus Attentlon: Carnpus"w.,Q~ Attentlon: Tltle:~ I Nl.ll'lberof I I Nl.ll'lberof I I NlII'Iber of I

7 ~m~sname:. ~ ~ ~~: ~ City;~ state:~.zip: Number 01 Attentlon: Tltle:. ~m~s Name: Number 01 City:~ 5tate:~ 'Zlp:~ Number Tltle:. ~mpus Name: EngUsh Forms City:. state: 'Zip: Number 01 Altention:.... Tltle:~ c::::::j ~mpus Name:. City: state:.zip: ~~sname:. Engnsh Forms City: State:.Zlp: Number 01, Tltle:, c::::::j ~mpus Name:... City:_.. state:.zip: Number 01, ~pus Name:... A~ress: City: -'- state:~.zip:-. Title:. ~~s Name:. City: 5tate:_ ~.Zip: Tttle:. Engsh Forms c=j c::::::j Number 01 Campus Name:... A~~:.... c::::::j City: State:_ ~.Zip:~ Number 01 TItIe~' ~$' L..J-.t..,_~ 2097 East State St., Suite A Athens, OR (740) [1'W[ll.J'i!etlbnlll'.COlfi

8 Enroll online for quicker service at linsurance-kk.com or complete and mail this form Enrollment Form (School Year ) Student's Last Name: Student's First Name: Student's Middle Name:, ate of Birth: Street, City: State: Zip: Name of School istrict (required): Name of School: Grade Level: 0 Pre-K/Headstart o Kindergarten/Elementary o Middle School o High School/Above Signature of Parent or Guardian: ate: , Phone Number: Accident Only Coverage Plans 24-HOUR 24-HOUR Summer Only AT-SCHOOL HIGH SCHOOL FOOTBALl COVERAGE Full Year HIGH SCHOOL FOOTBALL COVERAGE Spring Only For New Players HIGH SCHOOL FOOTBALL and AT-SCHOOL Covers all athletics HIGH SCHOOL FOOTBALL and 24-HOUR Covers all athletics Student Insurance Plan Options - Check Your Selection: Low Option High Option 0$ $ $ $ $ $ $ $ $ $ $ $ $ $ Enclose check for total payment payable to: Nationwide Life Insurance Company. Checks, money orders, or credit cards accepted. O NOT SEN CASH TOTAL ENCLOSE: $ 173f(AOS_MUNG_03115) Mail this completed form with payment back to: K&K Insurance Group, P.O. Box 2338, Fort Wayne, IN Complete this section only if you wish to pay with a Credit Card Full name as it appears on card First Name: MI: Last Name:, Billing Address (if different than above) Street # Address Apt # City: Card Number: I II I I II II I I II II I I II II I State: Zip: ~=;=;:::::::::;--- I Expiration ate: Month: [I] Year: I! i Cardholder signature: Company does not issue refunds nor accept responsibility for cash payments. (Reiection of check or credit card by bank for any reason, will invalidate insurance.)