EmailMeForm
2024 - 2025 Enrollment Application
Student Insurance Plans Voluntary Enrollment
District
*
Please select
Allen ISD
Birdville ISD
Bloomington ISD
Brooks County ISD
Brownsville ISD
Comstock ISD
Crockett ISD
Denton ISD
Duncanville ISD
Edcouch-Elsa ISD
Frisco ISD
Granbury ISD
Grapevine Colleyville ISD
Groesbeck ISD
Hidalgo ISD
Hurst Euless Bedford ISD
IDEA Public Schools
Industrial ISD
Irving ISD
La Joya ISD
Lampasas ISD
Lancaster ISD
Lindsay ISD
Lockhart ISD
Lovejoy ISD
Marlin ISD
Marshall ISD
Melissa ISD
Mercedes ISD
Mesquite ISD
Point Isabel ISD
Premont ISD
Progreso ISD
Richardson ISD
Rio Hondo ISD
San Isidro ISD
Santa Rosa ISD
Sharyland ISD
Socorro ISD
Sulphur Springs ISD
Temple ISD
Wichita Falls ISD
Wylie ISD
Name of School Attending
*
Student Name
*
First
Last
Male/Female
Male
Female
Date of Birth
*
MM
/
DD
/
YYYY
Student ID Number
*
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Phone
*
###
-
###
-
####
Email
*
Parent Name
*
First
Last
Grades K-6 Plan Options
School Time Coverage - Standard Plan - $35
School Time Coverage - Elite Plan - $50
24 Hour Coverage - Standard Plan - $75
24 Hour Coverage - Elite Plan - $100
Grade
*
Please select
K-6
7-12
Grades 7-12 Plan Options
(School Time Coverage does not include any athletic participation. 24 hour Coverage includes athletics, but excludes high school football grades 9-12)
School Time Coverage - Standard Plan - $35
School Time Coverage - Elite Plan - $50
24 Hour Coverage - Standard Plan - $125
24 Hour Coverage - Elite Plan - $150
Optional Football Coverage Grades 9-12
(08/01/24 - 08/01/25)
Please select
Standard Plan Only - $275
Total
$0.00