College Student Insurance Plans & Affordable, Low-Cost Coverage

For NEW APPLICATION ONLY!
* Required Information

Student

Faculty or Staff

STEP 1. PERSONAL INFORMATION
Student First Name: *
Student Last Name: *
School State: *
Classification in School: *
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: *
(If your permanent address is overseas or Canada, please put US address here.)
Parents Address 1: *
Parents Address 2:
City: *
State: *
Postal ZIP code: *
Country:
Parents Email: *
Parents Home Phone #:
Parents Work Phone #:
Parents Fax #:

STEP 2. EQUIPMENT INFORMATION
Have you had any computer related losses in the pass 3 years?	No Yes Please explain if yes
Type of Computer:	laptop Desktop
Manufacturer:
Model:
Serial Number:
Please Note: You are not required to list additional items, but proof of ownership is required when filing a claim.
STEP 3. POLICY INFORMATION
Coverage Amount:	$2000 $3000
Select Deductible Amount:
Select Coverage Type:	With Accidental Coverage (Recommended) Without Accidental Coverage
Policy Start Date(mm-dd-yy):
Premium Cost:	$50
* 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:	$55 (Includes $5 processing fee)

Immediate Alert! Emergency Contact Program. You'll get $10.00 off the annual membership fee with renewal of your policy. Call us today 1-800-620-3051 to sign up.


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Student Insurance Partners, P.O. Box 2077 Stillwater, OK 74076. Toll free: 800-620-3307 Fax: 405.372.9584
E-mail: customerservice@studentinsurancepartners.com

STEP 1. PERSONAL INFORMATION

STEP 2. EQUIPMENT INFORMATION

STEP 3. POLICY INFORMATION