You are requesting a quote from the only endorsed and approved Student Accident Plan of Christian Schools International. Most schools require parents to pay the small premium per student when "registration fees" are sent out. By submitting the form below you will make a request to receive a quote for Student Accident coverage and numbers needed for planning. Our team will contact you regarding your specific schools' needs.

Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to CSI@StudentAccident.net

School Name:
Administrator in charge of Insurance Issues:
School Address:
City:
State:
Zip or Postal Code:
Phone Number:
Fax Number:
E-Mail:
Religious Affiliation/Associated Church (if applicable):
Pastor:
Association Affiliation
(Please list all national & state association affiliations your school belongs to in order to take advantage of rate guarantees.)





Do you currently have coverage?
Please enter the number of students at your school in each category. (Premiums are determined by multiplying the rate per student by the total number of students at your school.)
Daycare:
K-8:
9-12
Football (Number of Players):
Does your school participate in Interscholastic Sports?
Requested Effective Date: (mm/dd/yyyy)

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