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Student Enrollment Form

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

     
1. Name of School
2. Domestic/International
3. Insurance Company
4. Policy Number
5. Student Classification
6. Coverage Type
7. Coverage Term
8. First Name of Student
Last Name of Student
9. 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
  Email

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.
  

 


 
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