Mt. Lebanon School District Annual Notice

Mt. Lebanon School District Student Accident Enrollment Notice

After completing this form, a member of Kelly Insurance Group will contact you to complete the processing of your student accident plan.

Student's Name(Required)

First Last

Grade(Required)

Age(Required)

Gender(Required)

Guardian Name(Required)

First Last

Phone(Required)

Email(Required)

Student Accident Plans(Required)

24 Hour Coverage

School Time Coverage

This plan provides around the clock coverage to your child 24 Hours a day, while he or she is in school, at home or away. Coverage is provided from the effective date of the insured student’s coverage for which premium has been received by A‐G to the opening of the next school term. Excludes all interscholastic sports. ($124.00)

This plan provides coverage to your child while he or she is on school premises, during school hours/days, attending school sponsored and supervised activities including travel directly without interruption between the student’s residence and school/activity with transportation furnished by the school. Coverage is provided from the effective date of the insured student’s coverage for which premium has been received by A‐G to the end of the regular school term. Excludes all interscholastic sports. ($28.00)

Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Name of School(Required)

School District(Required)

Date(Required)