Please fill out the information below. Thank you for your business.
* Required Information
|
| Student First Name: * |
|
| Student Last Name: * |
|
| School State: * |
|
| Classification in School: * |
|
| Student Email: |
|
| Student Cell Phone: |
|
| Key Code: |
3 digit keycode found on bottom right of your application - if not found please leave this field blank. Example: z90 |
| Parents First Name: * |
|
| Parents Last Name: * |
|
| Parents Address 1: * |
(If your permanent address is overseas or Canada, please put US address here.) |
| Parents Address 2: |
|
| City: * |
|
| State: * |
|
| Postal ZIP code: * |
|
| Country: |
|
| Parents Email: * |
|
| Parents Home Phone #: |
|
| Parents Work Phone #: |
|
| Parents Fax #: |
|
| Coverage Amount ($2,000 - $20,000): |
|
| Select Deductible Amount: |
|
| Premium Cost: |
$97 |
| Policy Start Date(mm-dd-yy): |
|
* Would you like to add Immediate Alert for a special discounted price of just $29.95 (regular price is $39.95)?
Yes, I Accept. Create my IA Account.
No, Thanks.
Note: By choosing 'Yes, I Accept" above you are agreeing to our Service Agreement and Privacy Policy.
|
| Total Amount Due: | $102 (Includes $5 processing fee) |
| Note: Your coverage begins 24 hours at the location of your property after your online application for coverage approval. |
| |
