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 WAKE COUNTY PUBLIC SCHOOL SYSTEM Administration Services Division Risk Management
CERTIFICATION OF ACCIDENT INSURANCE To parent/guardian: The 6720.1
Every student participant in a student activity that requires accident insurance
shall be
required to:
A. Furnish proof of membership in the
student accident insurance program, or
B. Furnish proof that compatible
coverage is carried in another insurance policy.
6720.2 Student activities requiring student activity
insurance coverage are:
A.
Interscholastic athletic programs
B.
Intramural athletic programs
C.
Marching bands
D.
School patrols
E.
Cheerleaders
F.
Groups making
overnight trips or excursions Your child has indicated an interest in participating in a student activity that requires accident insurance coverage. Please check A or B below to indicate the method by which the required coverage will be provided. This form must be signed by parent(s)/guardian(s) and returned to your child’s school. I hereby certify
that___________________________________________________________________________
Name of
Student A. _____is adequately covered by accident,
health and/or hospital insurance policy that is in effect during the present
school year. This coverage is
through an insurance policy identified below: ______________________________________
_______________________________ Name of Insurance Company
Policy Number B. _____is enrolled in the WCPSS’s voluntary
student accident insurance program.
I understand that my child is covered upon receipt of the completed application
and receipt of the appropriate premium by the WCPSS. Policy provides maximum of
$5,000 payable for any motor vehicle accident and $100,000 for Gold Coverage;
$750,000 for Silver; or $50,000 for Bronze Coverage payable for accident while
on foot on a field trip. Parent/Guardian_______________________________________Date___________________________ Parent/Guardian_______________________________________Date___________________________ Form 1733, Revised 9/95; Revised 6/02;
Revised 4/03; Revised 7/05
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