Travel Accident 2024-2025 – Board Members Enrollment Form

Travel Accident 2024-2025 - Board Members Enrollment Form

If you have any questions or concerns, please contact PSBA Insurance Marketing Manager Torie Tezik at torie.tezik@psba.org. For information about Travel Accident Insurance and more, please visit PSBAinsurance.com.

As a "thank you" for your service, all member School Directors are automatically covered with a complimentary $150,000 death benefit while traveling to and from board-sponsored meetings. Additionally, members serving on Vocational-Technical or Intermediate Unit boards are covered. School Directors have the option to purchase an upgrade to 24-hour coverage as well as insuring their spouse and children.

Please note: this form only needs to be completed if you plan to upgrade from basic to 24-hour coverage.

Pennsylvania School Board Association: Policyholder

49937: Primary Coverage Policy No.

49937: 24-hour Coverage Policy No.

Director name *

First

Last

Date of birth *

Gender *

24-hour coverage* *

$37.80

Benefit coverage: $150,000 *cost includes a service fee

School entity *

Full name *

First

Middle

Last

Email *

Home address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone number *

Signature *

Clear Signature

Date *

The total cost will be calculated to proceed with payment.

If you prefer, you may submit the form online (bypassing the credit card step) and mail payment to:

PSBA Insurance

400 Bent Creek Blvd.

Mechanicsburg, PA 17050

Total

$0.00

Credit card