Welcome to The Allen J. Flood Companies, Inc.

	Becoming a Client
	College & University Students
	Student Health Center
	Claim Filing Procedures
	Claim Forms
	Contact Us

Student Enrollment Form

* Dependent Coverage may not be available, please check your plan brochure

Name of School

Domestic/International

Insurance Company

Policy Number

Student Classification

Coverage Type

Coverage Term

First Name of Student

Last Name of Student

Permanent Residence

Street Address

Street Address (Suite/Apt Number)

City

County

State

Zip

10.

Student I.D. Number

11.

Date of Birth

(mm/dd/yyyy)

12.

Gender

13.

Amount($)

14.

Dates of Coverage

15.

Have Dependents

Payment Options:

	Purchase with Credit Card
OR
	Print the enrollment form along with your check or money order and mail these documents to: The Allen J. Flood Companies, 2 Madison Ave, Larchmont, NY 10538. The check should be made payable to The Allen J. Flood Companies. *Coverage will not be in affect until the day immediately following the day we receive your check or money order. I have read the brochure describing the benefits and I understand the terms and conditions contained therein.